Psychiatric emergency room a 'bottleneck' for mental health care

One of the busiest entry points into Minnesota's mental health system is the psychiatric emergency room. Sometimes they walk in off the street or are brought in by police or EMS. Nearly always they are in need of treatment for mental illness.

On a relatively serene Monday morning, MPR's Tom Crann spoke with Hennepin County Medical Center psychiatrist Dr. Kathleen Heaney, who described what it's like in a psychiatric emergency room that is an important place for mental health services, one that is often over burdened.

Below is a transcript of their conversation, edited for length and clarity.

Dr. KATHLEEN HEANEY: We are the bottleneck and the canary in the mine, you might say, of our disintegrating mental health system. It was quiet today, but there are some weekends when every room is full, the emergency room is trying to send us more people, the police are bringing us more people, and we are unable to move people out of here. So it can be problematic at times.

• Related: Minnesota's Mental State

TOM CRANN: The thing we often hear about emergency rooms for physical health is that there is a large segment of the population who uses this as primary care, because they don't have other options, they don't have insurance. So something happens, they come to the emergency rooms. Are you seeing that happen in mental health as well?

HEANEY: Yes, we will see people here who come to us -- frequent-flyers is the word we'll use -- and we can see that they failed multiple appointments out there in the community, but they come here for their med refill. A lot of people can use us if they are seeking shelter, want to hide out from somewhere. So our job is to sort out and make sure that our limited resources go to the individuals that really need it.

CRANN: When I hear you talk about the intake process, it seems like there's a judgment that has to happen fairly early on about the patient, especially to decide to hold them here. How quickly is that decision made?

HEANEY: Well, if someone's throwing a chair through the glass triage out there, that decision is made rapidly. I'm being somewhat facetious, but the behavior can bespeak to whether they need to stay or go.

But, when an individual walks up to that triage desk, the nurse checks their vital signs, starts to get history to find out why they're here. The nurse asks them some questions, asks them if they're suicidal, if they feel if they want to hurt anybody, are they having voices or hallucinations, and if there's negative to all those things, then that person would not be held here.

But if a person seems to potentially be a danger to themselves or others, talking about wanting to kill themselves or saying that they think that Martians are making them dinner that evening, these would give us pause to evaluate further. It doesn't mean we absolutely put them on a hold right then, but we would have to consider keeping them here longer so that we could see what's happening, what's going on.

HCMC IS 'LUCKY'

CRANN: You're saying that this is an acute psychiatric facility and yet it's being fed in different ways: From people who are using it as routine mental health, to law enforcement not knowing what to do with somebody. Is that a sustainable model for mental health treatment?

HEANEY: Places that do not have acute psychiatric services have big problems, nationally, because people that have mental health problems are flooding medical emergency rooms, and they don't know what to do with this or how to handle it. It's a huge problem.

This hospital is lucky, and I believe my colleagues, the emergency room physicians across the hall, very much appreciate us because they can send all their problems to us. This is rare nationally.

The business that we're in is we're dealing with the untouchables. I don't say that in a derogatory way. But, these people in mental illness historically were considered demonized, or they were locked away. But now, after deinstitutionalization, which is a good thing, all these people who are unable to care for themselves or get access to their medication are wandering around homeless.

CRANN: Sounds like there's an issue occasionally of what people might call outside of your discipline a "revolving door." Is there a problem with patients that come in who really should be in other more chronic situations who are using this acute facility too often?

HEANEY: That's exactly right. It can be difficult to make these determinations. Because we are expected, who work in this field -- and we're aware of this because of the events that have happened over the past few months with shootings and so forth -- is that people think that the mental health providers are god, and that we can protect everybody and predict everything. And that's not true.

So, we do the best we can to determine if someone is a potential danger to themselves or others. But we certainly cannot predict what's going to happen all the time.

POLITICS OF MENTAL HEALTH

CRANN: You bring up an interesting question there: often when we hear the debate about violent crime, gun crime, everyone says, "Well, we need to make sure that we're treating the mental health aspect of this." And as someone who does this in an acute facility like this, what goes through your mind when you hear that argument being made politically?

HEANEY: I wish that they would spend more money in building and developing resources for the mentally ill and people who have chemical use disorders. It's very easy to point fingers and say, "Oh, as long as we find out everybody who's mentally ill, then the world will be safe."

But, every human being is capable of doing something and be temporarily out of their mind, whether it be drugs or terrible shock or whatever. Obviously there's degrees, there's levels of degrees. But the thing is, it's not so easy to say, "Oh we'll take care of the mental illness and register everybody and then everything will be safe."

Those people who are saying that should spend more time building facilities and putting money into the care of our mentally ill instead of dismantling it.

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