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Bipolar Disorder
Are We Headed for a Mad Max Society?
Cutting Inpatient Psychiatric Services Isn't Just Bad Policy, It's Crazy!
Posted October 1, 2010
Psychiatry is the only medical specialty that does not admit patients to the hospital based on how sick they are.
Psychiatrists in California have to dance around the state's civil commitment laws, written more than forty years ago.
Psychiatrists, in both the public and the private sector, also have to tango and tangle with utilization reviewers, people who carry clipboards and who do not have direct clinical responsibility for patients but are the ones who decide what care gets paid for and for how long.
Utilization review is just a slick euphemism for benefits denial.
I know I should know better than worrying about things that haven't happened yet, but I've already heard a rumor that the San Francisco Department of Public Health is thinking of closing down yet another acute inpatient psychiatric unit at San Francisco General Hospital, where I work as an attending psychiatrist in the psych ER.
This would take us from 42 to 21 acute beds. Lengths of stay are already shrinking. The revolving-door phenomenon is alive and well as unstable patients freshly discharged from the units bounce back, often within hours, to psych emergency.
Humane and reasonable treatment of the seriously mentally ill is costly, complex, and labor-intensive. The outcomes are often difficult to measure. It is convenient and seemingly cost-effective to not pay for even brief inpatient stabilizations. But the costs of not providing this safety net option show up in increases in ER visits, arrests, and incarcerations.
Hello, Earth to administrators, policy-makers, and utilization reviewers: Are you listening? You can't stabilize most acutely psychotic patients in three or four days. It takes ten to fourteen days to even do a half-decent job and years of research bears this reality out. What happened to paying homage to the "evidence base?"
But beyond these economic realities lies a potentially more remediable problem: that of seriously outdated civil commitment laws.
Two major problems exist with these obsolete codes:
One, the laws have psychiatrists focusing on trying to predict "imminent" dangerousness as the major criteria for holding people against their will. This is what I call the "crystal ball" standard.
Two, the laws assume that each and every person is competent to make decisions regarding treatment. And for the sickest of the sick, this is not the case. Lack of insight is a cardinal symptom of severe schizophrenia, schizoaffective, and bipolar disorder.
The system of care, then, is not much interested in taking care of patients who are sick but not dangerous. They repeatedly fall through the cracks and end up homeless, incarcerated, and victimized.
Sick patients who lack insight often stop taking their meds after a hospitalization. There is no mechanism in place to compel them to stay on their psychiatric medications. These people often abuse alcohol and drugs as well. Perhaps the next time they create a public disturbance they won't be brought to a hospital but instead to jail. How do you think the LA County Jail became the largest public mental hospital in the country just a few years ago?
So, if you suffer from a severe psychiatric disorder and have lost the support of friends and family, you still have your rights. But this is more the right to refuse treatment than to gain access to treatment. Sure, you can avoid the "coercion" of the mental health system, but good luck keeping yourself safe, fed, housed, clothed, and out of jail.
You have the right to be arrested when you're in the middle of a nervous breakdown.
You have the right to not be taken to the hospital and treated for your brain disorder.
You have the right to eat out of Dumpsters, get beaten up by thugs, get rained on, have rats go through your food, to crap in an alley, to pee behind a tree, to sleep in a doorway.
And as long as the maintenance of these "rights" dovetails with the priorities of society's bean counters who choose to spend less money on psychiatric care in both the public and private sectors, then the risk of us heading to a Mad Max society only goes up.
copyright 2010, Paul R. Linde, M.D.
Dr. Linde is author of "Danger to Self: On the Front Line with an ER Psychiatrist." His web site is www.paullinde.com.
