Funding cuts threaten mental health care

By JOAN YEA

Senior Staff Writer

It is common for mental health services to be targeted by funding cuts, which negatively affects not only individuals but also community resources. The emergency department (ED), in particular, has been noted for receiving an influx of mentally-ill patients following the closure of mental health facilities. The extent to which such extensive budget cuts to public mental health systems affect the ED has not, however, been well-documented or well-quantified.

For example, from 2009 to 2011, $587 million was cut from mental health services in California alone. Such sweeping budget cuts have necessitated that facilities such as the Sacramento County Mental Health Treatment Center significantly reduce the number of available psychiatric beds.

Between June and September of 2009, the Sacramento County Mental Health Treatment Center reduced the number of inpatient psychiatric beds from 100 to 50. By Oct. 1, 2009, the treatment center had completely closed its outpatient crisis stabilization unit, which had formerly been open 24 hours a day and seven days a week.

According to investigator Arica Nesper of the University of California Davis School of Medicine and her colleagues, this decrease in county mental health services created an enormous burden on the nearby ED of the UC Davis Medical Center. In a research report recently published online in Annals of Emergency Medicine, Nesper and her colleagues describe the impact of the closure on the ED’s patient flow, as indicated by the increased number of ED psychiatric visits after the reductions had taken place at the county’s treatment center.

Following the decrease in psychiatric services, the number of daily psychiatric consultations provided by the ED increased from 1.3 to 4.4. In other words, the ED provided more than triple the number of psychiatric consults in the eight months after the closure than in the eight months before the closure. Moreover, the average ED length of stay for patients identified with severe mental illness increased from 14.1 hours before the closure to 21.9 hours after the closure.

The investigators have found that, as the average number of daily psychiatric consultations and the length of stay increased, psychiatric patients had to wait longer in the ED before being transferred to an inpatient bed or a psychiatric hospital. Prior to the reductions in the county’s treatment center, psychiatric patients who required an ED bed occupied the space for about 19 hours per day, which increased to 97 hours once the closure was complete.

Commonly dubbed as “psychiatric boarding” in emergency medicine, this phenomenon encompasses both voluntary and involuntary patients who come to the ED with mental illness and who are ultimately detained in the ED for an extended period due to the shortage of beds in psychiatric units. Patients who are delayed in their transfer to an inpatient psychiatric bed or a psychiatric bed in another facility are also delayed in receiving necessary care. In addition, psychiatric boarding presents significant problems in the ED’s patient flow for both psychiatric and non-psychiatric patients.

Assuming that patients who arrive at the hospital with other ailments occupied an ED bed for four to six hours per day, the researchers estimate that the additional number of psychiatric patients may have affected the flow of patients to the extent that 13 to 20 patients that would have normally been evaluated in the ED were delayed in receiving care.

Since the researchers did not survey the effect of the reductions in the county’s treatment center on nearby EDs of other hospitals in the Sacramento area, they acknowledge that their findings may be reflective of the specific conditions of the single study site. However, psychiatric boarding has been recognized as a frequently occurring problem in areas that have a shortage of psychiatric beds. Recently, in the wake of the expanded mental health coverage provided by the Affordable Care Act, new policy measures have been taken to address the problem of psychiatric boarding in the ED.

In 2014, the Washington State Supreme Court ruled that, regardless of the shortage of funds, staff or facilities, mentally ill patients should not be detained in the ED without treatment. A mandate was also issued to increase the number of available psychiatric beds. This policy decision, according to the researchers, has important implications for mental health policy discussions and changes that would need to take place to address the current limitations of mental health care.