Wednesday, January 30, 2013

Until the next Newtown....a psychiatrist's frustration.

It has been more than a month since the tragic shooting in Newtown Connecticut. I have been listening to the pundits and newsies talk about what could have possibly prevented the tragic murders.  One huge faction is arguing that better gun control will prevent tragedies and one strong rebuttal to that argument has been that more attention to metal health issues will save us. I hear the arguments that gun control isn’t going to prevent any tragedies, and it is not my intention to prove or disprove that notion. As a psychiatrist currently working in community mental health, I just want to mention you might not want to put all your eggs in the mental health basket either. Let me explain:

Today at a community mental health facility I had two patients. One patient is a charming good looking young man, who on the surface doesn’t look like anything is bothering him, but he has auditory hallucinations that torment him and tell him not to trust his family and to kill them before they kill him. Today I spoke to his mother who told me her and her kids and grandchildren sleep in locked rooms afraid of what he may do on a whim.  When medicated he is pleasant cheerful, and very funny; but he isn’t taking his medication and today in this state he is anything but, and quite scary.

The second patient I had only one brief encounter and didn’t know very well. The report I got was he had been reportedly discharging a firearm in his neighborhood 2 days ago. I was told that he had been refusing his medication for weeks, and was held up in his apartment talking to the walls and yelling out the windows. The field agents who are charged with visiting his home and making sure he is ok were able to get him to come to the clinic by telling him they were taking him grocery shopping. Through a lot of hard work the community agents were able to bring these two men into the clinic for evaluation. Given the report of how these men were acting in the community I decided it would be safer if they were admitted to the hospital to have their medications adjusted. They both demonstrated demonstrable danger to others and potentially themselves. Sounds simple enough. Wrong. 

It is usually the job of the sheriff's office to pick up involuntary commitments in the community, so I filled out the paperwork for involuntary commitment and called the sheriff's office. My call was answered by a less than courteous dispatcher who told me they were in middle of shift change and they would not be able to send someone out until 7pm. It was 4:30 pm.

I explained that I had a staff of mostly females and that the patients were potentially dangerous when agitated. I let her know they were only here begrudgingly and it was only a matter of time before they became agitated. The dispatcher then transferred me to a shift manager whose disposition made the first person's curtness seem pleasant by comparison.

I again explained the situation and asked if someone could please transfer the patients to the nearest hospital. She rudely told me that shift change wasn’t until seven and even then I would have to demonstrate the patients had been given medication to calm them 30mins prior to their arrival.  I attempted to explain that as a private clinic I have no medication to give the patients. We are not a hospital or ER with shots to give agitated patients. She said then she would not send anyone. "So, you want me to send my deputies into danger with a violent 'crazy. person?" ,she asked. I explained these people with mental illnesses (not crazy people) were in need of medical help. The people who went into the community to get them were not trained, nor armed. Yet they went into the community to retrieve them, even with the knowledge that one may have been potentially armed. But she was telling me trained police officers with weapons and restraints could not handle two unarmed men?

As she was refusing to help one of the patients turned to the other and said "It's a trap, they're trying to lock us up". At which point both men began to get irate. I explained this to the person on the phone who heard this but still wasn’t moved one inch towards caring.

I then hung up with her and called 911. The 911 dispatcher, who at least was pleasant, explained that it was the sheriff's department's responsibility to transport involuntary commitments and that by law they could not. She said she would at least send a patrol car over to assess the situation.

          The patrol officer did arrive promptly, and he too was at least polite. By this time one of the two men saw the police, thus confirming his suspicion that he had been duped. He began cursing and pacing angrily. He was now visibly agitated, but thanks to the great community worker was able to be calmed. The officer who witnessed this suggested that now that the patient was calm and one of my workers should transport him to the hospital. When asked if he could at least follow them to the hospital he, again politely, said no. 

We then had to call off duty male staff in to ride with the female staff and patient to the hospital. Meanwhile the other patient, who introduced the idea of a mass conspiracy, began to rock in his chair, mumbling how he’d be damned if he was going to the hospital.  The police officer and I were sat and berated the sheriff’s department for not doing their job. The officer agreed that it was a shame that mental health services were in shambles. He talked about the time he spent as a community support officer. He went on to say that the sheriff’s office should have sent someone urgently despite being in the middle of shift change. It was in the midst of this conversation that the empathetic officer who just spent five minutes talking about his understanding of the broken mental health system informed me that he was leaving.  He told me he had to get back to his patrol. I asked him what I was supposed to do if these patients became violent while we waited the still whole hour left until 7pm. He responded that if they did become violent we could then call 911 and THEN someone would come.

Around this time some of our male staff arrived and the calmer patient was able to be taken to the hospital leaving me, two female staff members, and the patient who 2 days ago was reportedly shooting in his neighborhood.  Some more male staff came and I had to leave them untrained, unarmed civilians with the patient to wait for the trained armed sheriff’s office. Time 7:05

I wish that I was just venting about one bad experience with one bad county with one bad system, but I can’t. In my short career I have worked in two states three cities and numerous different counties and it is sad but I have had the same experience with the relationship between law enforcement in mental health in each of those settings.

I don’t want to touch the gun control debate that has come up since the last mass shooting, but I do notice that each time one of these tragedies comes up people mention mental health as the failed barrier that should have protected society from these tragedies. And I only mention the gun control debate in the same breath as mental health because I feel it is futile to say the current status of mental health care in this country will offer any help in the same way that it is viewed the status quo with regards to gun control will offer any addition safety to society at large. The major similarity between both discussions is that as soon as a great tragedy occurs we get really amped up to change the world. We posture and talk really grand for a moment and then nothing happens.

Why nothing really happens is because the problem is very complex and difficult to solve. In this story better communication between law enforcement and mental health services needs to happen. It can’t be just one department that is responsible to responding to a crisis if that department can’t be responsive 24 hours a day, and then an emergency department who is trained to handle potentially violent situations abdicates that responsibility to civilians when the situation is inconvenient for scheduling.

Coordination is one small facet of the problem but it is deeper still. Even when law enforcement agencies are cooperating there is no place to take acutely agitated patients. Mental health institutions have gradually been decreased over the last three decades. There are fewer and fewer long term treatment facilities. As a result, most acute inpatient hospitalizations are for less than a week and then patients are sent back into a community that is ill equipped to support them.  Because they are poorly supported with poor outpatient care they bounce back very frequently which creates a jam in ER’s across the country. Because ER’s are overflowing, there is more pressure to discharge patients quickly (not to mention the financial pressure to discharge quickly, but a separate conversation). Poorly stabilized patients decompensate quickly and end up back in the ER which starts the cycle all over again— leaving mental health providers very frustrated.

The legal system is equally frustrated because the patient who aren’t in the revolving door of ER->hospital->community->ER often make detours in the justice center. Jails aren’t equipped to handle serious mental illness so they try without success to access the above mental health system and find it just as jammed as described.

I really started this article to vent about a horrible incident I had, but my frustration wasn’t because of the time I lost that day or necessarily with the rudeness of some of the people I encountered. My main frustration was that as I sat and reflected the day’s event I came up with more problems than I had solutions for. Ultimately all of the solutions I could come up with involved the expenditure of monies. Most of this country considers things that improve living conditions for poor and indigent (which most of the severely mentally ill population falls under) entitlement spending. But I cant help to see it differently.  Money spent to decrease social stressors (assisted living, vocational training, community support staff etc, and access to medical care, etc) is not philanthropic, it is self preservation. Poor social support and substance abuse more than triples the likelihood of violence in mentally ill population.  Yet if I suggested spending money on the above no bills or referendums would pass, no media outrage would occupy the 24 hour news cycle, nobody would care—until the next Newtown. That’s what frustrates me.