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During the first day on the job, a psychiatry resident sees patients who need help, but there are problems with the system designed to help them.
It was my first overnight call shift, and I had just gotten a page for my third Emergency Department (ED) consult. I was the on-call psychiatry resident at the hospital, meaning I saw anyone coming into the ED due to a mental-health-related crisis. Many things can be categorized as mental health crises, but they are often cases dealing with suicidal thinking or action, psychosis, mania, and drug or alcohol use.
About 10 minutes after I got the page, I was sitting in the patient’s room listening to them describe the events of this past year between fits of tears. My heart pinched when I heard the inevitable: “I have been trying so hard to find anyone that can help, but the wait lists are so long…” In an ideal world I would have treatment options at my fingertips and distribute them with lightning speed to everyone coming to the hospital in a severe crisis. But, for many reasons, this is far from reality.
From the start of the COVID-19 pandemic, experts have warned of an inevitable mental health crisis that would follow the devastation of such a massive unprecedented event. Now, almost a year and a half since the virus was declared a global pandemic, this crisis has arrived. Despite this well-predicted and publicized outcome, not much was done to prepare systems. Importantly, few actually realize what a mental health crisis looks like at the frontlines—and just how many individuals and systems it affects.
The View from the ED
This July, I started my first year as a psychiatry resident. On our first day, the program director sat me and my fellow interns down to have a frank discussion about what we were walking into. With our brand-new ID badges, we listened as she described mental health care as a stream that ebbs and flows. And right now, she emphasized, it was a tsunami. The ED at our hospital was filled with what are called boarders. Boarders are patients that are in the ED exclusively for a psychiatric reason, but because the system is so backed up, there is nowhere else for them to go. So, what happens to them? They wait, and wait, and wait in a place never meant for more than an extremely short length of stay.
It is easy enough to read about the overflowing EDs, but something entirely different to witness it firsthand. Here is what it looks like: obtaining a patient’s history about a depressive episode resulting in a suicide attempt behind thin curtains, because there are no physical rooms available; telling a patient who is grieving for their spouse that we cannot immediately get them connected to a therapist because there is a shortage; telling a patient who has been waiting for a week already that they will need to wait over the weekend before they can get a bed somewhere else; limiting time for conducting therapy with any particular patient because other patients in acute crisis keep rolling in; and having a patient, who desperately needed a higher level of care, leave because the wait was too long.
An ED is not a long-term mental health facility, so when a length of stay in the ED approaches that of an inpatient psychiatry admission, there is a problem. The ED is an incredibly poor place for patients who are in a psychiatric crisis. The overall structure and function of most EDs is not designed to be therapeutic for someone experiencing an exacerbation of a mental illness. In fact, many aspects exacerbate mental health struggles, including interrupted sleep, loud noises, frequent unknown visitors, and lack of windows or activity.
There are incredibly important downstream effects, as well. With half or more than half of the ED’s beds filled by those awaiting a higher level of psychiatric care, there is less room and bandwidth for those seeking the ED for other reasons. EDs are often partially staffed with mental health and psychiatric services, but the demand for their services frequently surpasses these clinicians’ capabilities. Additionally, EDs filled with boarding patients are a substantial cost to the health care system, estimated to be $2264 per patient. And this cost was based on a boarding time of only about a day. With our ED patient list well over double its typical amount, it is safe to say that my colleagues and I were entering training during one of the most severe crises in recent history.
Looking for Solutions (In and Outside of the ED)
Solutions to psychiatric ED boarding were discussed even prior to the COVID-19 pandemic. Among them are: standardization of ED protocols for mental health and substance use issues; building partnership with community services; incorporating family and loved ones into care plans; and educating ED staff about trauma-informed care.
However, these ED-focused solutions do not address one of the major underlying problems: There is an ongoing inpatient bed shortage for both adults and children. Since deinstitutionalization, creating more inpatient psychiatry beds has not been a public priority—though in some states this is beginning to shift. It is important to note that there is extreme variability between inpatient hospitals, and the inpatient setting is by no means the only solution to someone in a psychiatric crisis. However, there is still a clear need for more long-term mental health care facilities.
Aside from insufficient infrastructure, there is a shortage of psychiatrists and other mental health professionals. With the scale of the current crisis, patients are hard pressed to find any therapist or psychiatrist without a waitlist or who is even taking new patients. There was already a shortage of mental health practitioners, and the mental health crisis sparked by the pandemic has only exacerbated this shortage.
The phrase “just take care of the patient in front of you” rang in my head for my entire first call shift. These were the words of one of my attendings during our emergency psychiatry orientation. It is not new to physicians to feel as if they operate in a broken system. However, this feeling has been especially strong while training amidst such a severe crisis.
Despite the systemic issues I saw that day, those words rung true: our job is to focus on the one patient in front of us and do the best we can with them. In some ways, it is hard to hold that idea alongside the equally important one of needing to advocate for our patients when the system is failing them. But while I will be trained on how to take care of the patient in front of me, figuring out solutions for system failures will be left to my precious amount of free time. For now, despite the continued unanswered calls to action, I remain optimistic and tuned in, ready to use my voice and experience to advocate for real change for my patients.
Dr Mulkey is a first-year resident at the University of Vermont Medical Center