(July 27, 2017) Before patients are admitted to inpatient units, many are repeatedly discharged to their homes or the streets from hospital emergency departments. As a psychiatric emergency clinician in Massachusetts, I see this happening too often. Patients are not sufficiently stabilized when they are discharged from emergency departments and inpatient units prematurely.
The police department is inundated with calls from people who are delusional when they fail to take their recommended medications. They request that the police protect them from "people" who exist only in their paranoid delusional states.
Overwhelmed, they asked me to help. I went with police officers to the apartment where a man resided alone. I contacted his rehabilitative outreach team to inquire about him. The team members explained that since he had been released from a psychiatric inpatient unit months ago, he had not engaged with them for services.
Approaching the man, we could see he had wrapped bed sheets and towels fastened together with tape and staples around his body covering much of his head and face. He said his neighbors were using rods to prod at his body, so he needed to protect his body, hence his appearance.
Inside the home, the man had covered his fire alarms and electrical outlets with papers. He expressed his belief that "they" were emitting laser beams through these with the intention to kill him. He told us that he has no mental illness, thus doesn't need any medications.
Despite our attempts to persuade the man to accept hospitalization, he refused. I authorized the involuntary hold and he was transported to the hospital.
Just hours later, the hospital emergency department discharged this patient to his home. I believe that his lack of desire for inpatient treatment contributed to his untimely release, which I had no control over. Whether or not a patient wants help is not part of the criteria to qualify for inpatient care. If a person with psychosis is lacking awareness of being psychotic, this person cannot understand that treatment is needed.
Appropriately timed treatment for someone who is acutely psychotic prevents further deterioration. One solution not available in Massachusetts is assisted outpatient treatment (AOT). AOT helps to ensure that people with severe mental illnesses who have been extensively non-compliant with their medications and outpatient appointments become treatment compliant. It's difficult seeing patients in need get neglected because I care about them. It's as if the hospital doctor sent a message to the officers and me stating 'your work today was unnecessary.' Although this feels frustrating to me, there is hope in believing that our work was needed. We added to the evidence showing the need for AOT. I’m a proponent of AOT and believe if it is ever adopted in Massachusetts, the revolving door could be slowed.
Please visit my blog to learn more at https://breakdown-emergency-psychiatry-book.blogspot.com.
Lynn Nanos, LICSW
Massachusetts