Mental Health in Today’s America.
“I can’t pee,” he says.
“They froze my urethra! They got mad that I didn’t listen to them. To punish me, they froze my urethra. Now I can’t pee.”
“Who froze it?”
The voices froze his urethra.
He’s a good-looking man. His tan sets off his silver buzz cut and nonblinking eyes. He’s wearing blue paper scrubs, our mandatory mental health outfit. He’s wearing them well.
The blues help, even though many hate them. They remove the risk of hidden weapons that could harm them or others. They prevent them from overdosing on pills stashed in their underwear. They set them apart from the other patients, those who can come and go as they please. Blue patients only get bathroom privileges. The paper is too flimsy to hang yourself with. It saves on laundry.
I smile back. That’s better than being cursed, punched and spat at.
I probe further.
“How did they freeze it?”
“By remote control. They put in a chip.”
Wow! I wish I had that technology! It would work wonders. No more adult diapers! No more Foleys! It would even help heal decubitus wounds! A dream!
I sigh. I get back to here and now. I have to ask the question. The danger question.
“Have you had any thoughts about hurting yourself or others?”
“No. Not me. The wolf-pack.”
“They told me to kill myself. I didn’t. That’s why they froze my urethra.”
Sometimes it’s the FBI. Sometimes it’s Jesus. Sometimes it’s the devil. Today it’s the wolf-pack.
I’m working a blue shift today. I get my usual share of heart attacks, STDs and diarrhea, but I’m also in charge of half a dozen or so mental health patients. They’re all waiting. For medical clearance, mental health evaluation, a psychiatric bed, a safe place to go.
In our community ER, we have three “mental health safe” rooms. They’re stripped of everything but the stretcher. That’s seldom enough. Blue patients have to lay in the hallways in plain sight. They sleep, they eat, they get bored, they watch the action. Until they become the action.
Some are sick, like Mr. Wolf-Pack. Psychotic, manic, catatonic, despondent. Like Cat-Woman. She thinks she’s a cat. She won’t talk. She refuses to eat anything but cat food. There’s no cat food in the cafeteria. I tried milk. She hissed at me.
Some metabolize yesterday’s liquor. They got drunk. They got into a fight. They said they’ll kill themselves. Somebody called 911. They’re waiting for a mental health eval.
Kids out of control. Some as young as five. They had a temper tantrum. At home or at school. Their adults called the police to bring them over, hoping for a magic potion to make them into little angels. Thirteen-year-old Johnny has developmental delays and autism. He’s been with us in the ED for 23 days. There is nowhere for him to go. He sleeps a lot. He plays cards with the staff. Until he gets angry, rips his blues and throws feces at us.
Some are demented. The nursing home sent them here because they bit their nurse or they peed in the sink. They didn’t know she was their nurse, and to them, the sink looks just like a urinal. They don’t know where they are, nor why they’re here. Neither do I.
Some suffer from debilitating chronic pain, and they can no longer stand the suffering. They’ll kill themselves if I don’t give them Dilaudid or Xanax. Preferably both.
Some feel unloved and they need attention. They took a double dose of Motrin, tried to strangle themselves with their bare hands or scratched their wrist with a paperclip.
Some are lonely and hopeless. Their wife of fifty years died; the dog, their only friend, got run over by a car; the kids never call.
They all wait for hours, days, weeks, in the ED purgatory. They get bored watching the walls. They get needy. They need nicotine patches, sandwiches, a third warm blanket, a fifth cup of coffee — not decaf — with four sugars and milk. They need things we can’t provide.
They swallow curtain rings and forks to buy themselves an endoscopy, and the sedation that goes with it. They punch the walls. They eat paint. They get angry. They try to elope. They fight. For their safety and ours, we need to sedate and restrain them.
They need love. They flirt with the other blue patients. They get attached to the staff, who go home after their shift, making them feel rejected. They wait. They wait for a long time.
The lucky ones go home.
Some will come back tomorrow, and the day after that, and the day after that.
Some get admitted. Some return the day after they get discharged.
Some have no place to go. They can’t be on their own. There’s nobody to care for them.
The prevalence of mental health illness in the US is staggering. One in five adults. One in four for young adults, as per the National Institute for Mental Health. Less than half received mental health services. “In 2017, among the 46.6 million adults with AMI, 19.8 million (42.6%) received mental health services in the past year…”
It gets worse. As per NIMH, half of our teenagers suffer from a mental disorder: “Based on diagnostic interview data from NCSAS, the lifetime prevalence of mental disorders among U.S. adolescents aged 13-18… 49.5% of adolescents had mental disorders. (Out of those,) an estimated 22.2% had severe impairment (based on) DSM-IV criteria”.
Mental health treatment is elusive. The National Alliance for Mental Illness, “half of all chronic mental illness begins by age 14; three-quarters by age 24. Despite effective treatment, there are long delays—sometimes decades—between the first appearance of symptoms and when people get help.”
Why? The reasons are many, and complex. These are some:
Not enough beds. The Treatment Advocacy Center,: “From their historic peak in 1955, the number of state hospital beds in the United States had plummeted almost 97% by 2016. Even when private hospitals are included, the number of psychiatric beds per 100,000 people in the United States ranks the nation 29th among the 34 countries in the Organization for Economic Cooperation and Development. Without access to hospital care, acutely ill individuals deteriorate, families and caregivers buckle under stress, ERs fill with acutely ill patients waiting for a bed to open and police and fire responders find themselves increasingly diverted to mental health calls. By 2014, 10 times more people with serious mental illness were in prisons and jails than in state mental hospitals, a circumstance widely attributed to the shortage of beds to provide timely treatment.”
Not enough psychiatrists. The American Association of Medical Colleges states: “the need for treatment is expected to rise as the number of psychiatrists falls. In 2025, demand may outstrip supply by 6,090 to 15,600 psychiatrists…A number of factors fuel the shortage, including a greater awareness of mental health problems…, mental health providers frequently are reimbursed less than physical health providers, leaving institutions struggling to cover salaries… there’s a retirement drain: More than 60% of practicing psychiatrists are over the age of 55—one of the highest proportions among all specialties…”
Not enough money. Few uninsured can afford mental health care, when one hour of therapy may cost $300 or more. Even for the insured, copays may be too much. Due to low reimbursement, many mental health providers don’t accept insurance. MHA,: “…22.94% of adults with a disability were not able to see a doctor due to costs…People with mental health problems have a 2.5 to 7 times greater odds of facing barriers to medical care and 50% of (untreated) adults…didn’t receive treatment because of costs.”
Refusal of care. Some mentally ill people refuse care. They are often the sickest. Involuntary commitment is the process through which an individual posing danger to themselves or others can be committed to mental health treatment against their will. It’s a thorny subject. Commitment has a bad rep after centuries of being used by powerful people against their opponents. Commitment laws differ from state to state.
Bernard A Krooks, Esq, explains: “In 1999, several incidents occurred in New York City…individuals with untreated mental illness became violent and caused severe harm or death to others…In one incident, Andrew Goldstein, a 29-year-old man diagnosed with schizophrenia, pushed Kendra Webdale in front of an oncoming N train to her death. Subsequently, Julio Perez, a 43-year-old man with mental illness, pushed Edgar Rivera in front of an uptown 6 train causing the loss of his legs. Both Goldstein and Perez had been discharged by psychiatric facilities with little or no medication.
Kendra’s Law, Section 9.60 of the NYS Mental Health Law, provides a life-saving tool for families, as it can compel an individual to undergo psychiatric treatment… It grants judges the authority to… require people who meet certain criteria to …undergo psychiatric treatment. Failure to comply could result in commitment for up to 72 hours.”
Consequences of mental illness, especially untreated, are devastating. NAMI states:
- Serious mental illness costs America $193.2 billion in lost earnings per year.
- Mood disorders…are the third most common cause of hospitalization in the U.S. for both youth and adults aged 18–44.
- Adults…living with serious mental illness die on average 25 years earlier…
- Over one-third (37%) of students with a mental health condition…drop out—the highest dropout rate of any disability group.
- Suicide is the 10th leading cause of death in the U.S. and the 2nd leading cause of death for people aged 10–34.
- Each day an estimated 18-22 veterans die by suicide.
The relationship between mental illness and criminality. As per Washington Post :
- Untreated severe mental illness is particularly significant in homicide… even more significant for mass murders of strangers.
- Treatment of severe mental illness can greatly reduce violence by and against the mentally ill.
- Many mentally ill who seek treatment do not receive it. Mental hospital beds per capita in the U.S. are lower than they have been since 1850.
- Over the last half-century, mental hospital capacity has dwindled, while prison and jail capacity has vastly expanded. Mentally ill prisoners comprise a large fraction of the… prison population.
- Compared to imprisonment, treating… in a mental hospital is at least four times as expensive, on month-by-month basis. Nevertheless… availability of treatment in mental hospitals could be cost-effective… Ninety days in a mental hospital might avoid the need for 10 years in prison…
- Because many… mental illnesses (such as schizophrenia) are degenerative, early treatment is especially helpful. Preventing a first episode of psychosis… can have major lifetime benefits.
- In situations where a…mentally ill person presents a grave danger to others…, involuntary commitment may be necessary. Due process should be protected… Involuntary commitment should not require that the danger to others be “imminent.”
Mass Shootings. One well-discussed aspect of mental health relates to gun control. Americans disagree over the role of mental health in mass murders. Should we control guns? Should we control people? While we debate, the shootings continue.
The LA Times: “at least 59% of the 185 public mass shootings.. in the US from 1900 through 2017 were carried out by people who had either been diagnosed with a mental disorder or demonstrated signs of serious mental illness prior to the attack. Mother Jones found a similarly high rate of potential mental health problems among perpetrators of mass shootings — 61%… considerably higher than… in the general population… about 15 times higher than the rate of serious mental illness found among American adults.”
Of note, the risk of violence is higher in people with dual diagnosis – mental illness and substance abuse.
American mental health care is in crisis.
The mentally ill suffer. So do their families. So does my ED, choking under the burden of psychiatric patients with no place to go. Society suffers. Mental health illness affects us all. Mr. Wolfpack, Cat-woman and Johnny need help. Helping them and others will make us a better society and a better country. We need to find the resources to help our vulnerable, our endangered, our needy. Helping them will help us all.
If you need help now:
NIMH: If you are in crisis, and need immediate support or intervention, call, or go the website of the National Suicide Prevention Lifeline (1-800-273-8255). Trained crisis workers are available to talk 24 hours a day, 7 days a week. Your call goes to the nearest crisis center in the Lifeline national network. These centers provide crisis counseling and mental health referrals. If the situation is potentially life-threatening, call 911 or go to a hospital emergency room.
Rada Jones MD is an Emergency doctor in Upstate NY, where she lives with her husband Steve and his black deaf cat Paxil. She authored three ER thrillers, OVERDOSE, MERCY, and POISON.