Poor Prognosis for Mental Health Care in Texas' EDs
By Robert Greenberg Texas Medicine February 2015

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Commentary — February 2015

Tex Med. 2015;111(2):25-26.

By Robert D. Greenberg, MD

Texas emergency departments (EDs) endure daily challenges due to a lack of resources and competing priorities in dealing with mental health disorders. This burden is further felt by our community partners in emergency medical services (EMS), law enforcement, the courts, and dedicated mental health resources. 

As an example, one Saturday morning, one-third of the patients turned over to me had mental health problems with little hope of finding appropriate services over the weekend. Saturdays during the day are not so bad, but the usual Saturday night and Sunday mayhem was still to come. What was even more worrisome to me was that nobody seemed surprised. The problem is, it is now "business as usual" to board patients in EDs as we scrounge for scarce mental health services. It is not just a lack of inpatient beds but also a lack of community services and other outpatient treatment options. 

The presence of boarded patients of any type has a profound effect on throughput and efficiencies of our already stressed EDs. The resulting disruption to the care of other patients and the burden on the staff are tiresome. Add to that the strains of close (but not too close) observation mandated by rules and regulations, frequent reevaluations, and the need for additional personnel with the inability to provide care directed at the primary problem, and you have a recipe for a predictably volatile environment. At times, the frustrations are palpable. At least, on the bright side, my patients were not taken to jail or denied care. 

Too much of our mental health care is relegated to law enforcement, even to the extent that some county jails now seem to be the primary providers of mental health care. It is embarrassing that we task law enforcement with so much of the delivery of care.

That said, the best things we have seen recently are the creation of crisis intervention teams (CITs) and the opening of sobering centers. CITs are local initiatives to improve how law enforcement and the community respond to people experiencing mental health crises. Sobering centers are facilities with a safe, supportive environment where publicly intoxicated people can get sober and be directed to other community services as an alternative to being booked into the local jail or spending the night in an ED.

Why has medicine become such a passive participant in something we call a disease? A big part of the answer is because the risks are high and the benefits to our patients and to ourselves seem low. The obsolete Texas mental health laws that still seem to regard psychiatric disease as a crime are partly to blame.

Physicians should have the authority to hold someone impaired by psychiatric disease to keep him or her from causing harm to himself, herself, or others. I hope all in medicine agree we have that ethical responsibility, even without the legal authority to do so. In Texas, we must rely on a peace officer to come to the ED or a judge to provide us the authority and protections to provide emergency medical care to those who are an imminent danger to themselves or others due to their psychiatric disease. 

Unfortunately, the Texas Legislature has been unable to pass a law to provide for physician-initiated holds, even though it has been brought before them repeatedly over the past decade. (Read "Protecting Patients, Society," November 2013 Texas Medicine, pages 29-32.)

To further confound the situation, some of the smarter criminals have figured out how to hide in the mental health system as the more impaired with mental illness are drifting through the jails and the courts and enduring lengthy waits for forensic mental health evaluations. 

The situation has been exacerbated by some facilities abandoning mental health care due to overly burdensome regulations, the threat of sanctions, and resultant negative publicity. That leaves those left ever more hampered by the patient load, the ambiguous and illogical regulatory requirements, and lack of resources. 

Finally, and worst of all, we are letting down those we are supposed to serve. Patients and their families assume we have the authority and resources to care for them. We clearly do not. The prognosis for significant improvement is poor with a full recovery unlikely. 

Robert D. Greenberg, MD, is regional medical director of emergency services for Baylor Scott & White Healthcare Central Texas Division and is the director of the Division of Prehospital Medicine in the Department of Emergency Medicine in Temple. He is also chief of staff at Baylor Scott & White Emergency Medical Center in Cedar Park.

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