A statewide shortage of psychiatric beds means increasing numbers of mentally ill Jackson County residents are held for days without treatment in Harris Regional Hospital’s emergency department, sometimes in handcuffs.
Psychiatric boarding, dubbed “warehousing” or “dumping” by mental health advocates, is overwhelming North Carolina hospitals after years of state scrimping. Emergency department doctors and nurses receive limited training in diagnosing and treating psychiatric disorders, and physicians typically confine care to giving patients their medications. “Our emergency department doctors are wonderful, but they do not feel expert in behavioral health issues,” Chief Nurse Executive Anetra Jones said.
Each year, about 150,000 North Carolina residents with psychiatric and addictive disorders crowd emergency departments. Many are involuntarily committed because they are dangerous to themselves or others. This includes children; a 5-year-old spent several days in a neighboring county’s hospital a few years ago. Locally, county deputies, Sylva police and Western Carolina University police officers deliver an estimated 200 involuntary commitments each year to Harris. Residents seeking psychiatric help also walk into the emergency department voluntarily.
Once there, these mentally ill patients – sometimes psychotic and combative -- are confined to small rooms. They stay two to five days awaiting for one of 875 state psychiatric beds: down by half from a decade ago. The recommended wait? No more than four hours, according to the Joint Commission on Accreditation of Healthcare Organizations.
Mental health patients siphoned through hospital emergency departments say the experience can be agonizing. “The employees don’t have training in dealing with people like me. They don’t understand, and they are afraid,” said Angel McKinney, a 28-year-old Cullowhee resident. McKinney was repeatedly hospitalized as a teen after being diagnosed with schizophrenia. As an adult, she experienced the state’s mental health system from the other side when she helped commit her friend's mother. Nothing has changed, McKinney said. The hospital’s employees couldn’t calm the suicidal woman, and her confusion and fear turned to terror when deputies pulled out plasticuffs and strapped her wrists. Harris asks officers to use handcuffs only as a last resort; in this case, McKinney believes the restraints were unnecessary. “It just scared her more,” she said.
A 2008 report by the U.S. Department of Health and Human Services found untrained medical personnel sometimes view psychiatric patients “as frustrating (and) puzzling.” This can lead to “disrespect and hostility.” Psychiatric boarding, the federal agency said, “often creates an environment in which a psychiatric patient slowly deteriorates.”
The state is promising reforms. The N.C. Department of Health and Human Services plans to divert psychiatric patients when possible from emergency departments into community-based programs. On Nov. 7, DHHS Secretary Aldona Wos said the $8.3 million blueprint includes walk-in crisis centers so assessment and treatment can take place quickly; community detox centers; an emergency hotline for veterans; faster intervention when children have mental health problems; and connecting more hospitals to the state’s telepsychiatry network. Using the technology, psychiatrists assess and treat patients through video conferencing.
Harris is already considering telepsychiatry. LifePoint Hospitals, the principle owner in the Duke LifePoint partnership that bought Harris this year, has a contract for its 60-hospital chain through a national telepsychiatry company. Adding the technology won’t end psychiatric boarding, however. Harris CEO Steve Heatherly said the root issue is “access to care.” In addition to a bed shortage, North Carolina lacks psychiatrists. Jackson County doesn’t have one and neither do 27 other North Carolina counties.
Without a voluntary fix, North Carolina one day might earn an involuntary order of its own. Ten mental health patients in Washington sued that state over psychiatric boarding; on Aug. 7, they won. “Patients may not be warehoused without treatment because of lack of funds,” Washington state Supreme Court justices ruled. Rather, they must “receive such individual treatment as will give each of them a realistic opportunity to be cured or to improve his or her mental condition.” Psychiatric boarding is unconstitutional and breaks Washington state law, the justices wrote in a unanimous opinion.
Washington patients described their state’s mental health system as dysfunctional. North Carolina’s isn’t any better, according to Western Carolina University student Joshua Wilkey, who calls it a “train wreck.” Wilkey, 33, helped involuntarily commit his mother twice. She has bipolar disorder and chronic depression. “Patients, at best, are treated as criminals. Or, at worst, as sub-human,” he said.
Six months ago, during his mother’s last hospitalization, Wilkey’s mother shared a room with another patient in Harris’ emergency department. “Here’s someone who is going through something immensely personal, forced to discuss intimate problems while someone with a broken leg is lying next to them on a gurney with only a thin curtain in between,” Wilkey said. Her stay was relatively brief: two days. During those 48 hours, her son pressed relentlessly for his mother to receive the psychiatric care she needed. “It’s kind of like a rat’s race, with me saying, ‘Look, you need to find a bed. There’s not one? Try harder.’ The squeaky wheel seems to get the grease, and if there is no one actively advocating, people get shifted to the side and forgotten.”
In 2001, Gov. Mike Easley privatized North Carolina’s mental health system. Advocates said unleashing a competitive market and ending direct care through state agencies would increase community options for patients and reduce the need for psychiatric beds. It didn’t.
Instead, psychiatric boarding is clogging emergency departments, hospital officials say. With up to five psychiatric patients at a time in Harris’ emergency department, the nine rooms don’t always empty fast enough to meet demand. This leads to slowed medical response for everyone. It also wastes money. Wake Forest University researchers in 2012 found psychiatric boarding cost $2,264 per patient when they added together hourly payments for beds with dollar losses from low patient turnover. The study’s conclusion is likely conservative, because researchers studied an academic hospital with an in-house behavioral health unit. Patients there wait hours, not the 3.2 days the state averages in getting a psychiatric patient a bed and treatment.
“We would not condone this treatment for our pets,” the Wake County chapter of the National Alliance on Mental Illness concluded in a 2010 review of psychiatric boarding in North Carolina. Four years later, and “I think things have gotten worse,” said Ann Ackland, who helped prepare the NAMI report. Ackland believes North Carolina lacks the leadership and political will needed to improve its mental health system. “There’s a lot of talk,” she said. “But I just don’t see anyone caring enough to really do anything about it or a public that is outraged.”