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Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry

  The Broken System of Emergency Psychiatry 

–by Lynn Nanos

The mental health system is deeply flawed. I wrote the newly published book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, to appeal for legislative reform because it’s nearly impossible to change the system as a clinician. Breakdown traces key events in the history of the system: the mass closing of hospitals; the dramatic decline of inpatient lengths of stay; and the narrowing of civil commitment criteria.

Breakdown Nanos

Overly restrictive, involuntary hold criteria often result in only the most ill getting admitted to inpatient units. When they are deemed appropriate for inpatient care, they can languish in hospital emergency departments for weeks, or even months due to the severe shortage of inpatient beds. Or, they excessively wait because inpatient admission units refuse to accept some of the most challenging cases. Those most prone to violence are most likely to get stuck for months on inpatient, while those without health insurance inevitably wait for treatment the longest. Breakdown recommends that these inpatient units be held accountable and face consequences for this type of discrimination.

Meanwhile, patients who fake the need for care are swiftly moved to inpatient settings. This population occupies limited bed space. Although the most common reason for malingering is to secure shelter and food because of homelessness, other reasons exist. They might have just encountered a drug-deal-gone-wrong and are in danger of getting killed, thus need to hide out. Or, they might want to build a case to try getting financial benefits from the government.

Another commonly encountered group involves patients with borderline personality disorder. Their danger involves being most at risk for accidentally killing themselves. I usually do not grant inpatient admission to the patient who desperately wants this, hasn’t engaged in severe self-injury recently, and doesn’t have a suicidal plan. But I ensure that the patient who tightly ties clothing around her or his neck gets transferred to safety.

Breakdown is dedicated to the severely mentally ill population because they are grossly under-served in both the mental health and legal systems. For people with psychosis who lack awareness of being psychotic, the book closely examines Assisted Outpatient Treatment (AOT). AOT helps those who are not adhering to their outpatient treatment plans. It involves court-ordered adherence to these plans, that typically involve medication. The evidence in favor of AOT uniformly shows that it reduces rates of homelessness, incarcerations, violence, poor self-care, and hospitalizations.

Detailed case vignettes demonstrate interactions between patients, their families, police officers, and other mental health providers as they try to prevent danger. Yet, the system limits professionals’ ability to help. Administrative pressure leads to premature discharges. When patients are insufficiently treated, symptoms worsen, and readmission to emergency services is inevitable. They may become homeless, jailed, harm themselves or others, or die. Breakdown seeks to prevent tragedy by offering solutions for reform.

Lynn Nanos

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