Hollie, 25, is disabled and struggles with mental illness; over the past few years, she estimates, she’s been hospitalized nearly 40 times. Last week was one of those times.
When Hollie presented at the ER, she says, she was struggling with thoughts of taking her own life, in large part due to the isolation of self-quarantining during the coronavirus pandemic. It took her seven hours to be admitted, in part because the hospital in the Iowa city where she lives had cut its number of available beds in half, as a way to adhere to social distancing measures. The staff, she says, was “terrified,” and discussed with the patients not having access to available personal protective equipment (PPE) after a potential exposure the week before.
“They were always making sure they wouldn’t come near us,” she says. “The only thing anyone would talk about is how long this could possibly last.”
Hollie was lucky to even have a bed at her local hospital to begin with. In some areas, the number of beds has been reduced significantly and admissions severely restricted, and there are reports of ERs turning patients presenting with psychiatric issues away altogether. Providers report not having adequate PPE, or having to comb through red tape to offer teletherapy services. And patients in urgent need of psychiatric care may spend hours, if not days, languishing in the purgatory of the ER and awaiting beds in inpatient facilities that may not exist — both options that, by virtue of their healthcare setting, put them at increased risk of contracting the virus.
Many providers also warn that the real mental health crisis is yet to come. “We’re seeing what oceanographers would refer to as a drawback, before the big wave comes in,” says Dr. Jack Rozel, president of the American Association for Emergency Psychiatry. “I think we’re on the precipice of [an increase in demand].”
In coronavirus hot spots such as New York City, many psychiatric wards have been converted to wards for COVID-19 patients. Despite the extreme stress of living in a pandemic, many hospitals are currently running at as much as 50% below capacity, due largely to people being too scared of contracting the virus to present at hospitals, says Dr. David Roane, Lenox Hill Hospital’s chairman of psychiatry, who says capacity has “not been an issue.”
But that’s not the case everywhere, and certain populations are presenting at psychiatric units in increased numbers. Robin Henderson, PsyD, chief executive of behavioral health for Providence in Oregon, says she has seen an influx of adolescents and teenagers, particularly those with eating disorders, as well as seniors. “It’s pretty dangerous to figure out who to admit when we’re talking about populations that are most at risk [of COVID-19 complications],” she says.
To reduce overcrowding and adhere to social distancing measures, some hospitals are reducing census, or patient numbers, limiting patients to one per room where possible. In many hospitals, patients are also instructed to stay in their rooms, spend less time in communal spaces, and engage in one-to-one rather than group therapy.
“A hospital may have 100 beds, and what they will do is bring it down 20 to 50 percent during this time to maintain social distancing,” explains Travis Atkinson, a crisis systems consultant in behavioral health care. “Everyone’s trying to do what’s best for the people they serve and for their employees, but if communities have a psychiatric bed capacity issue to begin with prior to COVID-19, this certainly exacerbates that issue.”
With fewer beds immediately available, patients with urgent psychiatric needs who present at the ER must languish in the ER, often with other patients who have medical concerns (including COVID-19) if the hospital does not have a dedicated psych emergency unit. “It’s never a good time to have to board for a psychiatric bed in an ER, but this is definitely a bad time,” Rozel tells Rolling Stone.
Typically, a patient in crisis would present at an emergency room while staff would determine whether they presented a risk to themselves or others. If they meet the criteria for in-patient admission, either to the hospital’s own dedicated psychiatric unit or to another unit, the staff would try to find the patient a bed so they can get the appropriate treatment.
But the nature of this pandemic has made this process more complicated. Many patients are understandably reluctant to present at ERs, where they often can be in close proximity to patients with other urgent medical issues (many of whom may be presenting with symptoms of COVID-19, in areas that have been hard hit). Those who do present at ERs are typically patients who do not have access to such services as outpatient care or teletherapy, and are therefore on the lower end of the economic spectrum, providers told Rolling Stone.
Like many crowded institutions in which people live in close quarters, residents of psychiatric hospitals have been particularly vulnerable to coronavirus. At Western State Hospital in Seattle, an inpatient psychiatric hospital, 22 patients have been diagnosed with coronavirus, with one elderly patient dying. In Kentucky, 13 residents of a psychiatric hospital tested positive for novel coronavirus. In New Jersey’s four state-run hospitals, there have been at least four deaths and 80 people to test positive. There is precedent for such rapid transmission outside of the country as well. In one psychiatric hospital in South Korea, 99 out of 102 patients tested positive for the virus last month.
Healthcare workers are understandably concerned about such reports, particularly since they say they’re not given adequate PPE to deal with potential positive cases. In a survey administered by Atkinson’s consulting firm in partnership with the American Association for Suicidology (AAS), overwhelmingly behavioral healthcare workers said that inadequate PPE was one of their primary concerns. Seventy-one percent of staffers of mobile crisis teams, an alternative to in-patient psychiatric hospitalization who meet people in crisis in the community face-to-face, said that a lack of critical supplies was their primary concern: “We have suspended the majority of our mobile responses due to lack of PPE for staff,” said one staffer, while 70% of staffers at crisis residential programs said they also lacked sufficient PPE, and that staff had chosen to resign or take a leave of absence as a result.
Anna, who asked to be identified by a pseudonym due to fear of professional retaliation, is a psychiatric consult at a psychiatric hospital in northeastern Georgia. She says that ER staff is currently just wearing surgical masks rather than N95s, which they have to reuse day after day. When she brought up the issue with her boss, “he said, ‘It’s more psychological,’ meaning that the masks give the patients the appearance of safety, over them actually being a safety measure for us,” she says. “It makes people think we’re doing something, but it’s not doing anything for the workers.”
If a hospital has had any confirmed COVID cases, other psychiatric hospitals with more beds will be less likely to take any patients, regardless of whether they test positive or not. “The crux of the problem is we’re trying to get people out as quickly as possible but we have less beds available,” says Anna. “We’re finding that we’re really having a limited choice of where these people can go. So they just sit in the ER until we can figure out what to do with them.”
Sometimes, this means that their 1013, the state of Georgia’s code for involuntary psychiatric hold, will run out, and the patient will simply have to go home without receiving treatment they need. At one point, Anna had to turn away a patient with low-grade psychosis in order to conserve beds; Anna’s hospital has also instituted a policy not to intake adolescent patients in order to free up beds for adult patients, forcing them to lay in wait in ERs for hours before ultimately being sent home.
“If a person actively needs hospitalization and is showing symptoms of psychosis or is suicidal, we have to jump through more hoops, and it is usually taking longer to place those people,” she says. “And that is frustrating. And it makes my job harder.”
The rapid transmission of the disease, combined with the crowded conditions of many hospitals, has prompted many state officials to take drastic action, either by releasing patients or refusing to accept new ones. In Kentucky, for instance, Gov. Andy Beshear issued an edict that Western State Hospital in Hopkinsville would stop accepting new patients. At Western State Hospital in Seattle, officials are not just limiting admissions of new patients, they are currently trying to find community placement for 60 civilly committed patients, including those who had been determined by a court to pose a danger to themselves or others.
But discharging patients comes with added risk, as many severely mentally ill patients are homeless and may have no choice but to return to crowded shelters. “When we have these broad orders that say shelter in place or people need to stay at home, thats wonderful, but many of these people don’t have a home,” says Rozel. Mobile outreach is also not an option for many of these patients: “We’re trying to be proactive and call people who are living with serious mental illness. But some of them are homeless and it’s harder to find them,” Henderson says.
As caseloads reach their peaks in various states, psychiatric hospitals are also bracing themselves for the oncoming onslaught of patients in crisis. “The longer we are in this period of extreme uncertainty with people being isolated or quarantined or concerned, we’re gonna see increasing issues with serious mental illness and behavioral health problems start to emerge,” says Shawn Coughlin, CEO of the National Association for Behavioral Healthcare. “We saw it very much so with the Great Recession and we know there’s significant implications with the [current] unemployment rate.”
But this impending crisis is coming at a time when people are being encouraged to stay out of the ER and out of hospitals to begin with, making it all the more difficult for mentally ill people — particularly those with few financial or healthcare resources or social support systems — to seek the care they so desperately need. And while there are other services to fill the gap, such as distress support helplines, mobile crisis centers, and teletherapy, such services aren’t immediately accessible to the most disenfranchised of psychiatric patients.
Barring an infrastructure in place for remote psychiatric treatment, even for those who are fortunate enough to find a bed and gain access to in-patient services, the effect of such treatment can only last so long. When she was in the hospital and could interact with other patients, Hollie says, “we talked mainly about how isolation was terrible and how hard it would be outside the hospital again once we were discharged. Because then we’d be isolated again.”
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