A 14-year-old boy languishes in a windowless cell-like room in Multnomah County. He’s been there for two days, alone, with a “sitter” watching him to make sure he doesn’t try to kill himself. He gets three basic meals and is allowed to exercise a few minutes a day.
No, this is not a tale of an adolescent serving time in solitary confinement in an adult prison. This is a typical patient we see in the Portland-area emergency department where I work. The increasing number of individuals coming to Oregon EDs for psychiatric illness, along with a general lack of inpatient beds, has led to this all-too-common situation known as psychiatric patient “boarding.”
People coming to the ED with a psychiatric emergency are typically brought in by ambulance, police or a concerned family member, often precipitated by a violent act or threat of self-harm. They’ve likely been poorly functioning in their homes, schools, prisons or the streets. They need inpatient psychiatric treatment, and, if they pose an imminent risk of harm to themselves or others and do not agree to stay, we must “hold” them against their will. In reality, inpatient beds are rarely available, so individuals board in the ED, often for days, awaiting transfer to a psychiatric inpatient bed somewhere in the state. During this time, patients may lack the capacity to understand what’s happening and they have little control over their fate. Care is transferred from one provider to the next as shifts change, with no consistency or continuity.
The dysfunction of our entire mental health system is tragic, but the practice of psychiatric boarding is barbaric. If you put an otherwise high-functioning person with excellent coping skills in a room without windows, without human contact except for someone staring at them, with minimal exercise, for days on end, the experience would traumatize. For someone with mental illness, not understanding the system and not knowing what to expect, it’s devastating.
After hospital discharge, individuals go back to their bad situations. They often have poor access to counseling or medication and lack the ability to navigate an inadequate and dysfunctional system. Their lack of access to effective treatment can lead to self-medication with alcohol, prescription painkillers and illicit drugs. This, sadly, can lead to addiction, perpetuating a downward spiral. They return to the EDs, or end up in prison. We know many of them well.
The situation is dire, but there are some things we could do to make a difference:
1) Focus scarce mental health resources to schools, to community mental health centers and to addictions treatment programs to lessen the need for crisis intervention. The question of whether someone must board in the ED is challenging, but by the time we are even considering the question, it’s too late.
2) When someone must be held against their will, get them out of the ED as soon as possible. Invest in effective alternatives, such as respite centers or intensive outpatient programs, to avoid the costly care provided in the ED. And, frankly, we need more inpatient psychiatric beds.
3) If an individual must be observed by a “sitter,” have the sitter be trained in patient interaction. Ideally, sitters would have gone through similar experiences themselves and could offer much-needed empathy and insight.
4) After hospital discharge, provide reasonable transition services so people aren’t doomed to failure when they go back to the “real” world.
Oregon has the fourth fewest psychiatric beds in the nation – a meager 8.7 per 100,000 people. EDs are increasingly filled with individuals presenting with mental illness and/or addiction problems, and we are keeping them for longer and longer. Not only are these individuals suffering due their illness, but when psychiatric boarding takes up ED beds, emergency physicians can’t see patients who come in for heart attacks, strokes or other emergency medical conditions. The time to act is now.
Sharon Meieran is an emergency physician practicing in the Portland area.