Acute mental health system needs more study. (President's New Freedom Commission).
"Too often, budget shortfalls have led to reductions in funding for other essential community mental health services, consequently increasing the demand for already limited inpatient care as an alternative," Dr. Norwood W Knight-Richardson, chairman of the subcommittee focusing on acute care, told the commission. "The commission has heard accounts of communities where emergency departments are overwhelmed with patients in extreme psychiatric distress who have nowhere to go.
"The acute care system has become the safety net, and it is not designed to do that," he said.
According to the subcommittee's report, the total number of inpatient psychiatric beds per capita has declined by 62% since 1970, and psychiatric beds per capita on the state and county levels have declined by 89% over the same period.
Much of that decline, members said, has come as the mental health system has diversified its services with community facilities, home care, and urgent care services. "Part of it is a good thing, because hopefully we will need psychiatric beds only when it is absolutely necessary" said commission member Dr. Anil Godbole, chairman of Advocate Illinois Masonic Medical Center, Chicago. He added, however, that there is a "threshold" under which the number of psychiatric beds has dropped in many communities, destabilizing the entire system.
"There is a balance between the availability of services in the community that sustains people and keeps them functioning well and the need for acute care when that is not adequate," said Dr. Knight-Richardson. "Ultimately we would like for there not to be an acute care system, because we would like for people not to be so ill that they would have to be confined to that restrictive environment."
As the system tightens, Dr. Godbole said, more patients needing short-term care are being shunted into the wrong treatment facilities. "If people do not enter into the appropriate settings, then they get deflected into even more inappropriate settings such as criminal justice, law enforcement," he said.
Dr. Daniel Fisher, a commissioner and codirector of the National Empowerment Center in Lawrence, Mass., mentioned that the abilities of staff in acute treatment facilities are a crucial element in providing patients with correct treatment options. As an example, he recounted an anecdote about a client from Haiti who needed urgent care.
"The psychiatrist interviewed her in French because he was very fluent in French. She did not respond at all, and he concluded that she was catatonic and had her shipped to the state hospital," said Dr. Fisher, who said that subsequent discussions with Haitian community members showed that only 10% of the Haitian community at the time spoke French. "We set up an interpreter in the hospital to speak with her in Creole, and she was perfectly fluent and perfectly able to discuss her situation."
Dr. Knight-Richardson said he sees similar challenges in Oregon, where he serves as medical director of psychiatry at Portland Adventist Medical Center. There, the state's scant 42 psychiatric beds are full to overflowing with children, because of the system's inadequacies. Members said little available formalized data exist on the problem, though widespread anecdotal data do exist on the shortfall.
"There are hardly any data available for any of the levels of care," Dr. Godbole said.
The working group, the formation of which was approved by the commission, will be part of the recommendations set to be sent April 29 to the president.