Reinventing the E.R. for America’s mental-health crisis

https://www.newyorker.com/science/annals-of-medicine/reinventing-the-er-for-americas-mental-health-crisis

by if-curious • 3 years ago

117 107 3 years ago

Alternative title: "Bringing back the asylums without admitting we were wrong about closing them"

sudosteph3• 3 years ago

Did you read the article? It seems like this model actually results in fewer patients behind sent into hospitalization (which actually is like an asylum).

ceejayoz• 3 years ago

Hospitalization is very different from an asylum.

woodruffw• 3 years ago

This article is about emergency care; it has nothing to do with long-term mental health facilities like asylums. Did you actually read it?

mattzito• 3 years ago

This seems to be the opposite of asylums - put people in temporary care, give them treatment beyond just sedation and anti-psychotics, help get them stabilized, put together a care plan, and then send them home or to the next stage of treatment.

hanniabu• 3 years ago

and then send them home

In a lifetime of debt

lazide• 3 years ago

Technically that is already what is supposed to be happening.

Temporary holds however seem to have temporary effects, except for the trauma, legal side effects, bills, etc. anyway. 5150 holds are a bad joke.

wahnfrieden2• 3 years ago

those were prisons

77pt772• 3 years ago

Prisons were and are far better.

Those were endorsed torture centers with zero accountability.

Prisons don't even come close.

the-printer• 3 years ago

This comment is sensational, but the article here is eerily similar to one also on the front page published by the WSJ:

"It’s Time to Bring Back Asylums"

https://news.ycombinator.com/item?id=36826335

77pt772• 3 years ago

The asylum system was so much worse for the victims than homelessness that it's not even funny.

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.

babyshake2• 3 years ago

AI and computer vision could surely be helpful in a modern asylum or hospital setting, at least to help the humans better triage who most urgently seems to need their attention. The AI could also be used to communicate with patients but that's a bigger more long term goal with many more ramifications.

harimau7773• 3 years ago

Can you explain what policy you are advocating for? Asylums pretty egregious abuses of people's human rights; and that's to say nothing of instances where they were used to lock up mentally well but socially "undesirable" people. I'm guessing that you must have intended to advocate for something else?

willcipriano3• 3 years ago

Ok first check this out: https://www.dailymail.co.uk/news/article-12131455/Inside-Phi...

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.

NoMoreNicksLeft3• 3 years ago

Not that anyone ever did the mentally ill any favors when they were tossed out on the street...

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"?

retrac• 3 years ago

The mental health epidemic is real enough in terms of presentation to the ER. The numbers are quite shocking. Where I live in Ontario, Canada, psychiatric emergency calls involving the police have increased about 200 - 300% over the last decade. Many municipalities cannot currently respond to ambulance calls adequately, in large part due to responding to so many psychiatric cases. [1] This is not for any particular underfunding or mismanagement; the call volume has consistently increased far greater than anyone anticipated or planned for. [2]

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...

outlace• 3 years ago

Something is seriously wrong with our culture the past 10-15 years to have contributed to such a dramatic rise in mental illness.

zer8k3• 3 years ago

Is there a rise in mental illness or more people simply being diagnosed now? We're more aware of mental illnesses, leading to more diagnoses, leading to what appears to be a spike in mental illness. I haven't dug deeply into this but I wonder if studies on this have attempted to separate the two. Psychology is notorious for it's crisis of reproducibility. I take everything related to mental illness with two heaping scoops of salt.

coding123• 3 years ago

I don't know there seems to be a few things culminating - the pandemic and inflation. There are a lot of people that did not get the $10-25k pay raise that was necessary. Lots of people have gone homeless. Being without a home is one reason you can lose your shit. Also with the pandemic a lot of loved ones are gone forever. Some lost parents that takes a huge hit on ones mental state.

bmitc• 3 years ago

There is absolutely a rise. We live in a continually more digital and disconnected world, disconnected from each other and nature.

bill_joy_fanboy2• 3 years ago

One way to cut the nonsense is to look at things that can't be fudged.

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.

diogenescynic2• 3 years ago

When I was a kid growing up in the '90s, there was only one visibly homeless person and he was just a schizophrenic guy who pushed a tv around in a shopping cart. Now, there are tent cities and visibly mentally ill using drugs openly in most cities on the west coast. Something has definitely changed.

teekert• 3 years ago

Yesterday I spoke to a couple, they were having second thoughts about their holiday because there was no mobile internet and no wifi and they booked a week. At first I though their kids (11 and 16) were complaining (couldn't imagine otherwise), but no, it was the 40 y/o parents.

That's what addiction looks like to me, my wife and me were pretty shocked.

babyshake2• 3 years ago

At best, our technology messes with our heads somewhat. At worst, it leads to serious mental illness. Silicon Valley is creating the digital equivalent to forever chemicals in our drinking water.

bombcar• 3 years ago

I wonder how much can be attributed to legalization/decriminalization of drugs. Because if someone is on drugs but that is “fine” now are the classified as a mental illness incident?

flangola7• 3 years ago

Have you actually googled this at all? This reads like a question made in total ignorance of legal recreational substances, as well as their effects.

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.

dietketchup• 3 years ago

So you are talking about illicit drugs? Likely, none at at all. At least in the US, drug use is not considered sufficient to diagnose a mental illness. I'm honestly kind of confused by your question. What is a mental illness incident? I've never heard this term.

ProllyInfamous2• 3 years ago

The juice ain't worth the squeeze.

Social media has disconnected us all.

DNGAF. Amen.

keithalewis• 3 years ago

If you don't have anything to add to a discussion on social media then don't post.

nmfisher• 3 years ago

I can't talk about culture but in Australia, this definitely correlates with the spread of methamphetamine.

Meth-induced psychosis is a very real thing.

LilBytes• 3 years ago

Hard to say if positive outcomes for the average person in Australia started to decline before or after meth increased.

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.

NoZebra120vClip9• 3 years ago

So is methylphenidate-induced psychosis, mania, and suicidal ideation.

1234554321a• 3 years ago

20 years ago a mental illness, now they changed the name and it’s not an illness anymore so everything is ok.

edrxty• 3 years ago

Do you mind elaborating on what you're referring to so I don't have to assume the worst?

AndrewKemendo• 3 years ago

9/11 and the Global War on Terror pretty much killed anything like optimism and kicked off the rise in authoritarianism worldwide.

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.

diogenescynic2• 3 years ago

It's the potency and accessibility of drugs, now you can get fentanyl or meth that are dozens of times more pure and cheaper and available all over with virtually zero consequences. If you want to use drugs, there are no cops or doctors who are going to intervene and your family can't just force you into rehab. This new reality is simply sum of the cumulative bad decisions we've made--get rid of mental institutions, make health care unaffordable, tie insurance to employment so mentally ill and drug addicts have a harder time getting access to treatment, the breakup of the nuclear family, more females working and less time to raise their kids, decriminalize drugs, decriminalize sleeping outside in public places, decriminalize theft... this is the end result.

NoZebra120vClip9• 3 years ago

get rid of mental institutions

which dispense drugs,

make health care unaffordable

so patients can't afford drugs,

getting access to treatment

which starts and ends with drugs.

noelwelsh• 3 years ago

The root cause is, I think, inequality. See, for example, https://equalitytrust.org.uk/health

"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."

NoZebra120vClip9• 3 years ago

income inequality

Then is this the corollary to "Money Can't Buy Happiness"?

alex_lav• 3 years ago

I believe it is very clearly social media. Humans aren’t intended to have fake-insights into what people around them pretend to be doing

seltzered_• 3 years ago

The article has an insert section stating "Get Support If you are having thoughts of suicide, call or text 988"

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-...

ISL• 3 years ago

Might it also be associated with fewer deaths?

jjav• 3 years ago

There are endless news stories of police murdering some unfortunate mentally challenged individual when they show up. So, no.

jdietrich• 3 years ago

The facilities described in this article seem to be broadly similar to a "psychiatric intensive care unit", a care concept that has been developed in the UK and Australia in recent decades.

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.

lostNFound• 3 years ago

Just a tiny nitpick to avoid confusion, but a PICU is already a thing and it means Pediatric ICU, not psychiatric.

NoZebra120vClip9• 3 years ago

Would ΨICU be mistaken for a fraternity?

rootw0rm• 3 years ago

I propose πCU

ivan_ah• 3 years ago

Non-paywall link: https://archive.is/cEC5R

OldGuyInTheClub• 3 years ago

I think we've gone over the cliff on this and a lot of other issues like education and health care in general. If it isn't profitable for private equity it won't get done. If it is something that private equity gets into, the results are predictable.

It reeks of Dickens, "Are there no workhouses? Are there no prisons?"

obblekk• 3 years ago

There’s gotta be some reason for the mental health crisis, along with all the other crises out there.

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?

dec0dedab0de2• 3 years ago

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.

I would argue that we are not meanigfully wealthier in community, sense of purpose, love, and many other intangible things.

julianeon• 3 years ago

I don't know if mental health has necessarily changed for the worse, as much as we stopped locking people up in the attic (Victorian solution), or tossing them in the 'loony bin'.

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.

EgregiousCube2• 3 years ago

I think it has a lot to do with the birth rate. Here's a study from the prior century on the topic - there are a lot of correlated "people doing well" metrics, but when they controlled for fertility only it had the strongest negative correlation with suicide. https://pubmed.ncbi.nlm.nih.gov/1737819/

afavour• 3 years ago

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

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.

zzzeek• 3 years ago

People who even have health insurance are still going into bankruptcy when a severe illness like stroke or cancer befalls them. The US medical system still puts people into poverty due to medical circumstances every day.

kashunstva• 3 years ago

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…

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.

jaggederest• 3 years ago

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.

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.

rthomas6• 3 years ago

Well, for one thing we are all fatter, and the prevalence of depression in obese people has been found to be much higher than in healthy weight people. We are also more sedentary.

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.

stevenicr2• 3 years ago

"every level of American to be meaningfully wealthier" - I don't get this statement. I know a few people who own homes / property and they could perhaps qualify for this statement - but that gets into the weeds of they don't have that money in hand - sure they could sell, but they can't rebuy in the same city. Yeah second mortgages and of course when they die the property could convert to cash.. but they don't get to live much wealthier in general..

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.

plemer• 3 years ago

Wealthier, yes. But meaningfully wealthier?

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...

balderdash• 3 years ago

I think it comes down to less connectedness and community, fewer personnel connections, less religion/spirituality, less moral grounding, tech/media landscape that drives feelings of division/fear/inadequacy, generally less sense of purpose and belonging and self worth.

NoMoreNicksLeft3• 3 years ago

There’s gotta be some reason for the mental health crisis, along with all the other crises out there.

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.

ThinkBeat• 3 years ago

As someone who are been through this.

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.

cat_plus_plus• 3 years ago

I have a feeling that future generations of doctors will look at today's mental health care in the same way as we now look at bloodletting. Belgian town of Geel has demonstrated that many mentally ill can lead content, functional life with a different attitude from society. Current mental health care emphasizes drugs with uncertain mechanisms of effectiveness and severe side effects, and Freudian style therapy that presupposes that one's difficulties have a particular cause in the past that can be corrected through analysis.

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.

fnordpiglet2• 3 years ago

Technically I think Freudian analysis is very uncommon in a clinical setting in 2023. Most often it’s some variant of CBT, and for some conditions DBT, that have more outcome oriented approaches and frankly can be more systemically applied by less skilled clinicians.

orwin• 3 years ago

And also work long term, unlike psychoanalysis.

growingkittens• 3 years ago

What the original commenter wants is called "occupational therapy."

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.

Reinventing the E.R. for America’s mental-health crisis

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