Emergency rooms have become a place of last resort for the mentally ill. With increased demand on proper mental health facilities, the practice known as psychiatric boarding -- temporarily holding mentally ill patients in hospital ERs until beds become available at certified treatment centers -- has become a serious problem nationwide. Now, it’s an unconstitutional one in Washington state.
Last year, 10 patients in Pierce County, Wash., sued to end their involuntary detention on the grounds they were not being held at appropriate treatment facilities. During a preliminary hearing before a mental health commissioner, experts testified that patients held in hospitals commonly receive little or no mental health care. It is testimony backed up by a 2008 report from the U.S. Department of Health and Human Services that found that boarding “often creates an environment in which a psychiatric patient slowly deteriorates.”
Many states have laws authorizing the involuntary detention of people who pose a risk to themselves or others. Many of these states also regularly lack the space to place individuals in certified facilities. As a result, patients are held for days -- in some cases literally strapped to beds -- in emergency departments at acute-care hospitals until a bed opens up.
Psychiatric boarding has few defenders, even among health officials in Washington state. Still, state officials argued before the court that there’s little they can do about the problem without more money to boost preventive services or the number of beds at certified facilities. Washington’s high court didn’t agree, though, citing both U.S. Supreme Court and 9th Circuit Appeals Court rulings that said psychiatric boarding violates a patient’s basic right to “receive such individual treatment as will give each of them a realistic opportunity to be cured or to improve his or her mental condition.”
It’s a decision that could resonate nationally. Exact state-by-state figures aren’t available, but about half of all states admit to boarding patients, according to a 2013 survey by the health data firm NRI. In King County, Wash., boarding grew fivefold between 2009 and 2012, from 425 patients to 2,160. The Seattle Times found last year that the state cut 250 psychiatric beds and more than $100 million in funding for programs aimed at reducing detentions over the past six years. Nationally, states cut $1.6 billion from mental health budgets between 2009 and 2011.
Jim Vollendroff, mental health director of King County, is pushing to divert more involuntarily committed patients to other forms of treatment and is also advocating for more beds to be paid for in part with the help of Medicaid money. But that latter option comes with major restrictions, which mental health officials blame as one culprit in institutional shortages, in particular any restrictions involving paying for drug treatment.
While the ruling has heartened some in the mental health advocacy community, Robert Bernstein, executive director of the Bazelon Center for Mental Health Law, cautions against states simply providing more beds, which he argues often proves to be a more expensive and less effective alternative to quality community-based care. “Psychiatric hospitals need to be a part of the overall array of services, but it’s only part,” Bernstein says. States must also focus on more comprehensive community care, he says.
Unfortunately, about a quarter of emergency department medical directors say their areas lack the community-based services that Bernstein argues are crucial to treating mental health issues -- services that include mobile crisis units, case management teams that actively connect patients to services they need and clinics that also provide primary care.
In Delaware, state officials are providing those community services as part of a federal court settlement. It’s a possible model for other states grappling with the potential consequences of the Washington ruling. Delaware has poured about $12 million of additional money into mental health over the past three years. Since 2011 the average daily number of patients in the state’s psychiatric hospital has fallen 30 percent, and its hospital readmissions among people discharged to community care last year were well below the national average.