PROVIDENCE, R.I. — M is a 33-year old woman who swallowed silverware. She wasn't psychotic, or out of touch with reality. She knew it was not a good idea to swallow forks and knives and she wasn't trying to kill herself. In fact, each time she ingested utensils, she went to the emergency room so that doctors could remove them from her esophagus and stomach. Then the hospital transferred M to the psychiatric unit, where she was assigned to my care.
When I met M she had already been hospitalized 72 times. She'd swallowed silverware — and batteries — before. Sometimes she inserted sharp objects or large doses of medication into her vagina. There are psychiatric patients who cut or burn themselves in an attempt to relieve mental anguish; M did both of these things, too, periodically, but she had primarily developed a maladaptive habit of ingesting or inserting dangerous objects into her body as a means of coping with stress. Each time, she said, she felt better afterward. Then she brought herself to the emergency room for treatment.
M's case is dramatic. But she is one of countless psychiatric patients who have nowhere to turn for care, other than the E.R. It is well known that millions of uninsured Americans, who can't afford regular medical care, use the country's emergency rooms for primary health care. The costs — to patients' health, to their wallets, and to the health care system — are well documented. Less visible is the grievous effect this shift is having on psychiatric care and on the mentally ill.
Our failure to provide adequate psychiatric care to patients before they are in crisis affects us all. The lack of continuing outpatient care between hospitalizations leaves many psychiatric patients ill and often unmedicated. The consequences are felt in our communities, where the undertreated mentally ill are vulnerable to drug use, criminal recidivism (with additional court and incarceration costs), victimization and suicide.
The costs of M's repeated hospitalizations are staggering. Her ingestions and insertions incur the already high costs of hospital admission and the medical procedures and surgeries she requires. In addition, once M is hospitalized as a psychiatric patient, a staff member must stay with her at all times to make sure she doesn't ingest utensils from her meal trays, insert tools from group craft activities into her body or drink Purell from the dispensers on the unit walls.
How could this cycle of self-injury be disrupted? M and other psychiatric patients who turn to emergency rooms for care need regular outpatient appointments with a doctor they know and trust who can monitor their symptoms and assess the efficacy of their often complicated medication regimens. Sadly, M's history of recurrent hospital admissions is not uncommon. When people are admitted to the psychiatric hospital where I practice, their charts indicate how many times they have previously been hospitalized. Not infrequently, these numbers are more than twice the patient's age. Recently I treated a 65-year-old man caught in a chronic cycle of homelessness and suicide attempts who had been in and out of the E.R. 246 times.
If M had insurance, or enough money to pay out of pocket, she might see a therapist every week for an hour and a psychiatrist once or twice a month. Instead, she's treated by an overextended, publicly funded mental-health center where she sees a psychiatrist for 20 minutes, four times a year. Not surprisingly, her symptoms persist and she is hospitalized again and again.
In one of the ironies in a country with health care discrepancies, a single hospital admission for M — paid for by the taxpayer-financed state medical-assistance program — costs more than a year of private outpatient care would.
Our failure to provide a critical, basic level of outpatient psychiatric care to the mentally ill creates a volatile cycle in which uninsured or underinsured patients avail themselves of treatment only when they are in crisis. This is analogous to refusing to to treat hypertensive patients — or to monitor their blood pressure — unless they show up in the E.R. after having had a stroke.
The number of psychiatric patients seeking care in emergency rooms is rising. New research by the California HealthCare Foundation reveals that about half of the state's adults and two-thirds of the adolescents with mental health needs aren't receiving treatment. According to the Utah State Division of Substance Abuse and Mental Health, 69 percent of Utah's residents who need public mental health care do not receive any. In Rhode Island, where I practice, the National Alliance on Mental Illness reported a 65 percent increase in the number of mentally ill children living in public hospital emergency rooms following a series of state budget cuts. The increasing number of psychiatric patients relegated to emergency care creates a backlog in our E.R.'s, delaying or preventing medically ill patients from receiving necessary evaluation and treatment.
With budget constraints and a shortage of psychiatric hospital beds, patients must be deemed a danger to themselves or others to qualify for inpatient admission. In order to guarantee that they will be evaluated in the emergency room and then admitted for further psychiatric treatment, patients must convincingly communicate their dangerousness or distress.
In her last three E.R. visits, M has done just that. She registers at the intake desk, and then goes into the bathroom, where she swallows dangerous objects, or packets of pills. If M had a regular outpatient psychiatrist, she could call him or her in these moments of distress, schedule an urgent appointment, and obtain treatment and care from a simple phone call. But M does not have a relationship with a provider; she has a relationship with an institution. And the institution requires that M be in imminent danger in order to be treated.
We know that regular psychiatric care works. According to Dr. E. Fuller Torrey, president of the national nonprofit Treatment Advocacy Center, "Assisted outpatient treatment has proven to reduce psychiatric hospitalizations by more than 70 percent."
The Affordable Care Act may improve access to psychiatric care for the mentally ill. The act will extend health care to 32 million Americans, and the National Association of Psychiatric Health Systems reports that this "specifically includes mental health and substance abuse parity benefits."
But, in order to fulfill that promise, we will need to place new societal value on the importance of mental health. Until accessible, affordable mental-health care is a universal right, too many psychiatric patients will continue to receive the reactionary, crisis-driven care that is all our emergency rooms are equipped to provide.
Christine Montross is a psychiatrist and the author of "Falling Into the Fire: A Psychiatrist's Encounters With the Mind in Crisis."
Anda sedang membaca artikel tentang
Opinion: The Woman Who Ate Cutlery
Dengan url
http://healtybodyguard.blogspot.com/2013/08/opinion-woman-who-ate-cutlery.html
Anda boleh menyebar luaskannya atau mengcopy paste-nya
Opinion: The Woman Who Ate Cutlery
namun jangan lupa untuk meletakkan link
Opinion: The Woman Who Ate Cutlery
sebagai sumbernya
0 komentar:
Posting Komentar