Okay, so I want you to imagine that you’re a mental health patient in crisis. C’mon, you can do it.
Now, you have volunteered to come in, you have been picked up by the police, or you have been coerced by your family into coming to the emergency department tonight. You could have gotten to this point any number of ways. It’s three AM. The fact is, you’re being triaged by a very tired night nurse who is looking forward to seven AM report and freedom. Not blaming her for that. Not at all.
You are subjected to what is a pretty standard assessment nowadays in most EDs, including questions about your presenting complaint, your past history, the medications you take at home, and suicidal ideation or previous suicide attempts, and a substance abuse history. You might be screened for various illnesses, and if you say that you’re suicidal you get a few extra questions that allows the ED staff to assign a number value to your risk for self harm. At this point, or sometime soon after, a telepsycyh consult will be ordered for you if you are in one of the SC hospitals that is part of the SC Department of Mental Health Telepsychiatry Project. Funny thing is, up to this point you’re treated pretty much the same as the patient with congestive heart failure, poorly controlled diabetes mellitus or a hangnail. It’s after you are identified as a psych patient that things start to get a little restrictive. Well, a lot restrictive actually. Downright borderline abusive, if you ask me. But what do I know? I’m only a psychiatrist with twenty six years of clinical experience in the field. Ahem.
What happens to you next? What is done to you, without any input from you? You are wanded to make sure you have no weapons or contraband on your person. Then you are asked to remove all your personal clothing and dress in standard issue scrubs. Now granted, some hospitals have nice blue or green or purple scrubs if you’re into color, but still. Paper scrubs. Pretty flimsy and non-substantial. Your clothes and personal items are inventoried and put away for safe keeping. You cannot keep a watch, a cell phone or any other personal effects in most cases. You would be surprised, as I have been, how many people are not able to give me a contact number for family or even for their own spouse because the number is stored in their cell phone and they don’t know what it is! In most hospitals you are not allowed any visitors at all, even close family, for at least the first twenty four hours if not longer. You are pretty much cut off from everyone that might help you to feel safe, at a time when you are likely the most out of control you have been in some time. Make sense to you? Me neither.
You are then most likely put into a cubicle or bay or room that is isolated from other patients. Some of these rooms for psych patients have only a bed, or maybe even a gurney, to lie down on, no television, no reading material, no stimulation of any kind. Patients are constantly complaining to me about “staring at the four walls” especially if they have to wait in the ED for a psych bed to open up somewhere so they can get some actual treatment. Put a patient who is paranoid, agitated, hallucinating and frightened into a small windowless room, cut off from all communication with others and given nothing to distract him and what happens? That’s right. You guessed it.
Worse yet to me, many of these folks are told to get into the hospital bed or gurney, pull the sheets up, and lie there passively waiting for their assessment to be completed. That is perfecty fine if you have a kidney stone, have just been given narcotics and don’t want to move (yes, been there, done that a few times, thank you for asking), but if you are an agitated mental health patient, or if you are depressed out of your mind, lying passively in a hospital bed for hours or days is the worst possible thing you can be told to do. You should be up, dressed, stimulated appropriately, and distracted as much as possible from the symptoms that brought you into the ED in the first place. Most all of these mental health patients are not IV-in-arm, lie in this bed and don’t move kinds of patients.
Now granted, I understand full well that the hospital EDs must maintain a safe environment for both patients and staff. Patients who are truly suicidal and have expressed plans or are even at risk of acting on these urges in the ED must be kept safe. This often involves restrictions. But the vast majoriy of patients I see for consults in the ED are not like this. They do not need this level of restriction, and in my humble opinion I think it might be detrimental to them overall.
The bottom line here for me? Hospital EDs are so worried about controlling, restricting, and limiting mental health patients during their assesment and in the wating tme afterward that the issues that brought them in are exacerbated and actually harder to control. Anxiety gets worse, depression and despair deepen, hopelessness is heightened, and the patient who initially wanted help is thinking of nothing else but how to escape the prison that he now feels he is trapped in. “This is like being in jail, Doc. Sitting here looking at these four walls, no TV, can’t call my family. This is worse than jail.”
Do I have any opinions about solutions to this problem? You’re kidding, right? We’ll get there. I’ve got a lot more to tell you about before we get to potential solutions.
Stay with me.