Reinventing the E.R. for America’s mental-health crisis
newyorker.com
newyorker.com
If you've ever been in an emergency department, you'll know that it's far from ideal if you're experiencing an acute mental health crisis. EDs are often noisy, chaotic, and aren't equipped to provide the continuity of care and supervision that acutely mentally ill patients need.
A PICU isn't all that radical in concept; a service broadly similar to an inpatient psychiatric unit, but tailored to provide rapid access to short-term crisis care for the most acutely ill patients, as a stepping stone towards either a longer-term inpatient admission or discharge into community care. It's a very useful service that provides a much better alternative to ED admissions, but it's only part of a well-functioning mental healthcare system. If you don't have good community care services, you're just creating a revolving door.
The vast majority of people living with severe and enduring mental illness can live successfully and independently in the community, but they need a solid base of support from a multidisciplinary team to establish a stable and health-promoting life. It's not rocket science, but you do need joined-up care to support all aspects of wellbeing - medical care, substance abuse treatment where applicable, but also support with housing, work and community integration.
That kind of wraparound support obviously doesn't come cheap, but it's a heck of a lot cheaper than either locking people up in long-term institutional care or just patching up their most acute problems and sending them back out on the street.
I would like to see more focus on teaching people skills to navigate different aspects of self and others - dating, friendships, career, relaxing, finding something to be happy about. And also providing opportunities to actually practice those skills, modern society has become intrinsically stressful and isolating.
Obviously I am not talking about someone who suffered a complete break from reality and is sitting catatonic for days without interacting with anyone. But I bet a lot of patients admitted to ICU are not in this category, as evidenced by common sense measures described in the article working.
CBT, in application:
- is focused on quick results
- does not evaluate the patient as a system
- does not enable practitioners to recognize the limits of their practice
- does not have a concept of trauma as a barrier to using CBT.
This references my experience as a complex patient: I have a childhood brain injury that went undiagnosed until age 30. From 0-18, my parent's negligence hindered diagnosis; from 18-30+ I ran into the limitations of medical professionals and the medical system. In addition, I have read hundreds of experiences across time and space that align with these statements.
I have noticed that experienced CBT practitioners have a habit of seeing "failure to respond to CBT" as a failure of the patient to use it correctly. Less experienced practitioners are not as confident, and actually more open to the idea that their technique is wrong for the patient.
It's worth noting that this number has been associated with police interventions and a rise in psychiatric detentions: https://www.madinamerica.com/2023/05/psychiatric-detentions-...
Suicide is an example. You can't "overdiagnose" suicide unless you outright lie that it happened. The rate for suicide was something like 10/100K in 2001 and is hovering at 14/100K now. This is a significant increase.
If more people are killing themselves, it's almost certain that there are far more people are also miserable or struggling than there used to be.
This seems like pretty direct reasoning, but I suppose it could be flawed.
People have been outright lying about suicides for a long time.
It's kind of undeniable that there's a rising mental illness crisis in the US and undoubtedly more suicides, but keep in mind that suicide, like all symptoms of mental illness, is hard to track accurately. Especially as the stigma towards mental illness is starting to cede.
If it's counted as a suicide rather than an accident then maybe. I would then ask who is lying.
If it's faking deaths then that's the coroner system which you would have to question.
When looking at data, an otherwise healthy 20 year old, and an 80-something with multiple chronic and/or terminal Dx's, would stand out.
The challenge in looking at population-level data is that the Dx may well not be available, though other indicia might suggest this (e.g., residence is an assisted-living or long-term care facility). In practice, studies are frequently limited to available data, and proxies are frequently used. These may not be appropriate for specific individuals, but at scale, the law of large numbers and general correlation are your friends.
In 1999, teen (15-19) suicide was at around 8/100k, and it's now around 11/100k. It's lower in absolute numbers than in the general population, but there's still a disturbing uptick.
https://www.charliehealth.com/research/the-us-teen-suicide-r...
But it would be extremely unknowable whether or not they had experienced suicidal ideations, and how long they had had them. Because the most you will get is a note in the medical chart, based on a verbal claim by an unreliable narrator.
The reasoning being that it's very difficult to hide bodies, and that statistics on suicide tend to point to some very deep-rooted pathology within a society.
Yes, it's possible to fudge those statistics somewhat (the distinction between "accidental" and "intentional" deaths being salient), but far less so than other indicia of psychological trauma, particularly at population levels (the focus of sociology).
But you can do that. Throughout much of the 20th century (in the United States, at least), the cops might be willing to just call it an accident (he was cleaning his gun) or an unsolved homicide. Ostensibly to spare the family shame or to allow the family to bury them in the cemetery of their choice.
Furthermore, there seem to be factors that cause upswings and downswings in the suicide rate. There were alot more people jumping out of skyscraper windows in 1929 and 1930 than there were in 1925 and 1926, for instance (though we might expect the opportunity to have been roughly the same). Now, that doesn't directly rebut your argument here. But it would mean you'd need to show that if there is an upswing today that it has lasted longer or otherwise been worse than similar ones in the past, or that it doesn't seem to have the same sorts of causes.
If possible, it might actually be better to pick some other measurable event/behavior than suicide. Psychotic breaks, schizo episodes, or voluntary commitment.
That's what addiction looks like to me, my wife and me were pretty shocked.
I'm trying not to be insulting, but as someone who's social circle nearly universally consumes recreational drugs (not counting tobacco or alcohol), this comment is cringe-inducing how out of touch with reality it is.
To answer your question, 0% can be attributed to it. Alcohol has been legal forever, but medicine still recognizes what alcohol-related addiction, psychosis, and liver cirrhosis are. Medical diagnoses don't really care if the drug involved in a drug related symptom is legal to purchase or not. There are people who don't consume drugs of any kind and have many mental illnesses, and there are people who consume many drugs and don't have any mentally illnesses at all.
I think it's reasonable too assume that legalization of a formerly forbidden substance will increase overall use of that substance. I also think that it is reasonable to assume that increased use of a substance will increase the amount of people suffering the potential side effects.
That said, I think social media, the economy, the pandemic, pollution, and the war on terror drugs have done way more harm than legalized weed.
And then there are questions of whether you'll tell your psychiatrist. I've seen a quite accepting, non-judgemental attitude about recreational drugs, but can you count on this to be consistent? Do you want this on record in your medical chart? Do you want to try and consistently lie about activities quite germane to your mental health?
Social media has disconnected us all.
DNGAF. Amen.
As a recovered uppers abuser (sober over 14 years) I am grateful to care more than most peopls are willing to in such an unjust society.
"It is no measure of health to be well-adjusted to a profoundly sick society."
Meth-induced psychosis is a very real thing.
From my anecdotal (but significant observations), there's a coroally with people taking up hard drugs in townships where our youth have no observable pathways to a content adult life. It's my hypothesis people are giving up before they've started.
Regional Victoria and Regional Queensland, it's especially rife.
Edit: not to say other regional townships are worse or better, just haven't spent a significant enough time to observe it.
Throw in the 2008 recession and collapse in generational mobility worldwide.
Add to that global media/internet access and increasing alienation with the increase in inequality worldwide.
Finally top it off with a fat pandemic and you have at least two generations (X and Millennials) totally get their future put on hold while everyone older cashes out.
Everyone younger is looking at all this in horror and are just waiting us out while innovating humor in the most refreshingly gallows way.
which dispense drugs,
> make health care unaffordable
so patients can't afford drugs,
> getting access to treatment
which starts and ends with drugs.
"A much higher percentage of the population suffer from mental illness in more unequal countries; differences in inequality tally with more than triple the differences in the percentage of people with mental illness in different countries.
Rates of depression in US states are associated with income inequality (after adjusting for income, proportion of population with a college degree and proportion over 65). The more unequal the state, the higher the prevalence of depression."
Then is this the corollary to "Money Can't Buy Happiness"?
A lot of money seems to buy happiness, and when that pile of money is used to raise the price of housing / food / transportation - then those who do not have the big pile of money feel like they are hopeless and are often treated as such which has secondary effects.
It reeks of Dickens, "Are there no workhouses? Are there no prisons?"
From what I've read, 2/3s [1] of people who commit suicide have never sought any sort of treatment at all, so they'd never present at the ER in the first place or be candidates for hospitalization vs outpatient. If the suicide rate is still rising among that population, then that would probably disprove that. If it's not, then you may be right.
Maybe that was the focus for this exclusionary modeling.
Still, it is a lot of data to wade through, even under the most auspice of rigorous screenings for a purer validity.
In a lifetime of debt
We need to fix the legal system to allow people to get the help they need. If you even remotely think asking for help will get the cops sent to kick down your door and shoot your dog you won't go get help. Often times when you do get help it's too late.
Saying that someone with anxiety "needs help most" is unconvincing given the presence of psychotic homeless who aren't receiving treatment because of limited capacity or lack of financial incentive
I really don't understand your comment: why does a violent, untreated psychotic "need help less" than a neurotic who rejects the help for legal reasons?
The disagreement we have seems to be based on what the actual goal is of mental health intervention. It sounds like (correct me if I'm wrong) that you're saying the purpose is emotional growth. A neurotic is in more of a position to benefit from therapy than a psychotic. But I'm not considering things in terms of that, more so in terms of public safety
Temporary holds however seem to have temporary effects, except for the trauma, legal side effects, bills, etc. anyway. 5150 holds are a bad joke.
Those were endorsed torture centers with zero accountability.
Prisons don't even come close.
"It’s Time to Bring Back Asylums"
It existed just to hide these facts of life from the most fortunate and spare their feelings.
All at the expense of the committed that were horrifically abused.
And no, you won't do it right this time.
That's about 40 minutes from where I live and I can say first hand it isn't a exaggeration, since the pandemic those areas have been growing. Would you feel safe walking at night there? Now consider that children live in those communities. Do you think they feel safe?
I agree with you that many of the asylums were inhumane, shock therapy and the like. I think you'd also agree with me that modern asylums probably wouldn't be as bad had they been allowed to remain as they would've certainly been reformed over time. I am strong on personal liberty, and individual rights, However it is inhumane to those residents of those, very poor, communities to essentially have a open air asylum imposed upon them. Something must be done with these people, if not asylums what? Prison? I suspect that would have worse outcomes.
But it wasn't wrong to close them. They were torture dungeons where the government warehoused undesirables that it wasn't allowed to euthanize because we were supposed to be the good guys. Even now, they're literally a horror movie cliche... that doesn't happen by accident, it doesn't happen unjustifiably.
If you think that people want to bring them back without admitting that society was wrong to close them in the first place, how much of that is "I want the homeless to stop shitting on my front door stoop in San Francisco"?
It doesn’t make sense for every level of American to be meaningfully wealthier and higher income than 20 years ago and yet also be suffering (in multiple ways!) more as well. We even (mostly) fixed health insurance by massively redistributing income! The rest of the world seems to be tracking the same trends but 10 years behind.
It used to be that increasing people’s income improved all cause mortality. Have we crossed some threshold where that’s reversed?
I would argue that we are not meanigfully wealthier in community, sense of purpose, love, and many other intangible things.
Here's a novelty song from the 60's about those days.
https://www.youtube.com/watch?v=eQNI1KfGXBA
And here's a movie from a decade later, based on a famous book.
https://www.youtube.com/watch?v=OXrcDonY-B8
We don't deal with people that way anymore, but of course the problem remains.
It doesn’t? What if everyone is working more hours to maintain that income? Or taking on more stressful jobs and bringing that anxiety home with them?
I could believe that there’s a direct correlation between income and positive mental health in the very low bands of earning (i.e. living in poverty is stressful) but anything higher than that I’m dubious it’s so direct.
Maybe optimizing for a high and perpetually growing GDP is not in fact conducive to the mental health of those who generate it. But in any case, I’m not sure that it’s true that every stratum of US citizen has experienced income growth relative to inflation. Thomas Piketty’s analysis of US national income data points to a decline on the bottom end - a group that experiences disproportionately higher rates of mortality and morbidity.
In what sense is every level of American meaningfully wealthier? Only the top quintile has higher income than they did 50 years ago, middle and lower income people have all stayed stagnant in both income and wealth.
For another, most of us spend a lot of time on social media, the usage of which, at least for some demographics, has been strongly linked to depression. Also, due to screen usage and even LED lights interfering with melatonin production, we are getting one hour less sleep on average. That is actually an unreported crisis if you look into the effects of losing even one hour of sleep a night consistently.
Then there is the deterioration of social structures and "third places" such as church, clubs, and other social gatherings, which are shown to reduce depression.
Most people I know that do not own property are doing much worse today than they were 10 years ago, and 15 years ago - everything is more expensive, and they do not earn much more.. they would be better off going back 15 years with what they earned then and pricing for housing / food / cars being what it was.
I'm wondering in what parts of the country that this is inverse.
Money buys power and the political economy is zero sum, so: concentration of wealth -> concentration of power -> most people lose power -> most people's lives get worse.
And wealth has become much more concentrated. Consider that in the US: * billionaires increased their wealth by ~$5T during the pandemic [1]
* the top 1% own ~30% of wealth and the top .1% own ~13% of wealth [2]
* unlimited election spending by corporations and labor unions has been legal since 2010 [3]
* in FY2018, the top ten Fortune 100 companies receiving the most federal funding achieved an ostensible ROI on lobbying of 100,000% [4]
The trend is only picking up speed.
[1] https://www.oxfam.org/en/press-releases/ten-richest-men-doub... [2] https://www.statista.com/statistics/203961/wealth-distributi... [3] https://en.wikipedia.org/wiki/Citizens_United_v._FEC [4] https://www.forbes.com/sites/adamandrzejewski/2019/05/14/how...
Evolution adapted you and everyone else out there to live in a small band of 50-200 people who only had occasional contact with other bands of about the same size. You do not have the psychological machinery to deal with more than that. Because humans are intelligent, and can learn to compartmentalize, we've scaled to a global civilization of 8 billion, most of whom live in constant daily contact with thousands of others, including direct contact with strangers.
This causes psychological malfunction, especially in those experiencing other sources of stress. Non-genetic hereditary factors contribute greatly. Cycles of abuse, dysfunction, and so on.
The world population has doubled even since I first learned what it was in grade school. And, soon enough, it will crash in the other direction, further confusing and causing strife.
Humans don't scale.
COVID-19 greatly exacerbated this, but the trend goes back to at least the early 2010s.
The role of emergency services is clearly transforming; becoming rather routine really. We have scenarios where people are engaged in behaviour where the response is ambulance or police, at rates many times that happened just a couple decades ago.
I don't really know what to make of it. I think probably in part, it reflects genuinely worse mental health in society. But I think it may also reflect a change in perspective/view. I think we are more likely to believe we need expert outside intervention when presented with disturbed individuals; previous generations may have been far more reluctant to call the police because they would have not interpreted such a scenario as a situation that requires police or outside intervention. (The cops, as they will usually admit, know no more about how to handle a crazy person than the average person does.)
I'm not sure about elsewhere, but one major hole in the healthcare and social net here in Canada is that there is very little care available between acute crisis and normality. There are services (largely overwhelmed these days) to help people at the very bottom. But not much in the way to prevent their slide to the bottom in the first place. About half of people who present to the ER for a psychiatric reason in Ontario have never seen a doctor before for their mental health. [3] And it's not typical that they just snapped suddenly one day. They had usually been suffering for weeks or months, possibly longer, before ending up in the ER. We do need something like mental health urgent care, or ambulatory clinics. Like the clinics for when you have a broken bone, but aren't dying. Take some load off the ER.
[1] https://www.theglobeandmail.com/canada/british-columbia/arti...
[2] https://www.cbc.ca/news/canada/ottawa/paramedic-chief-ottawa...
[3] https://jamanetwork.com/journals/jamanetworkopen/fullarticle...
The first place they take you after triage at the ER is harsh, uncomfortable and at times dangerous for both staff and patients.
All your stuff is taken away, you get a hospital shirt and pants, then taken to a room with few comforts. Usually, a doctor will do the minimum of triage (again) as you enter the unit, or sometime after.
This is mostly to ascertain if you are likely to be a danger to yourselff and/or others. Which decides who much freedom you will have.
Spending time in your room that does not have anything in the form of distraction / games / or anything else is boring. Walking around the unit, or the common room can be dangerous if one or more patients are admitted who are not safe to be around other people.
These get moved or locked in usually pretty fast if possible.
Some also have physical health emergencies. One guy who was brought in had a rotting foot that required emergency treatment.
What I saw of it was a worthy of a horror movie, and the stench was considerable.
And yes you get people who sling fleeces, vomit violently,
Staying in your room is a reasonably good idea.
Then you have people who are actively suicidal or self harming. That will get you a dedicated nurse who stares at you / observes you at all times (at a safe distance with an alarm button) (if staffing allows).
Usually the next workday, (which is Monday if you are admitted on Friday) a doctor will come to perform a more thorough assessment and figure out a temporary list og diagnoses and a decision on where to move you. This might involve a second doctor / psychologist if its a complicated case
Then you get put on a list of what / where to move you when that unit has space available. (if they already do, you are moved as soon as possible) otherwise, you get to wait for a while.
So its harsh, uncomfortable, a bit dangerous, and sub optimal but I have learned why it is like this and I dont see a way to alter it that is ideal for everyone.
The nurses at the intake are hardcore. They have seen it all many times and it takes a lot to impress them, thrown them off. People having a psychotic break, streams all forms of nonsense, threats, paranoid delusions and they are not impressed. They are also usually fairly nice if they agree you are not dangerous to be around.
ER is not a place for treatment of mental illness, nor can it be. It takes people in and do their best to keep the person safe (Usually from killing themselves, sometimes for the staff to be safe) and a temporary diagnosis.
You are then either considered well enough to leave and get back to the real world, or sent to a long term care unit, which is a hell of a lot nicer that will start treatment, full diagnosis and so on.