Frequent-Flyer Patients: Are We Really Helping Them?

Jennifer J.* skips across the street, happy to be free. Her 5-ft 3-in frame practically floats to the bus stop that connects her to the apartment complex she came from. She's just spent 72 hours confined to an inpatient mental health unit at a downtown medical center against her will.

Of course, things were different Saturday night in the emergency room (ER). There, she spat at 3 ER nurses, struck a physician, and threw a bedpan at another patient before she was restrained and given high-dose neuroleptics to calm her down. The local police had brought her in after an alarmed neighbor called concerned about the yelling on their adjacent property and sounds of violence. After she threatened to kill herself by jumping in front of a car, she was redirected to the hospital, a destination different from that of her boyfriend-the county jail.

She was intoxicated Saturday-had been drinking the better part of a week, and using methamphetamines regularly. This was unveiled in her basic medical workup. By the time she arrived at the hospital, she was more unruly than ever. The combination of being handcuffed, intoxicated, tired, and overwhelmed, put her in no mood to work with anyone, even after she was given the chance to sleep until sober.

The state of Washington employs a system of mental health professionals (MHPs)-certified advisors and appointed designates-to oversee a civil hold and detainment for 72-hour observation in a mental health facility. The MPHs are often affiliated with the local mental health agency where individuals have elected to receive the bulk of their outpatient mental health care. Because of this affiliation, they often know the frequent flyers and can help arrange follow-up services and preserve continuity of care. In short, they were called, and served Jennifer her papers detaining her for 72 hours based on her expressed threats to her life, impaired judgment, and aggressive behaviors.

This was her fourth such detention in 2 months' time. Each time she was observed on the mental health unit and subsequently released after court proceedings because it was then apparent she was no longer a direct threat to herself or others. Continued violation of her liberty to protect her safety was no longer justifiable. This time was no different, and subsequently a hasty discharge was arranged. She was given a plan to follow up in a week's time at an outpatient mental health clinic and a short supply of meds that no one was sure she was taking in the hospital.

To some, this was a crisis averted; to others, an egregious waste of precious mental health resources that happens time and again. It depends on your view of how imminent a threat she was to herself or others at her presentation-an opinion, I've found, that varies widely. In Washington State, a layer of complexity is added by involving the MHP system, which can be a blessing and a curse. By focusing on this process, or on the availability of inpatient beds, however, we are missing the larger systems issue: allocating more resources to the creation of a solid continuum of care that emphasizes earlier intervention and prevention.

The creation of such services is costly and fraught with peril. In times of relative fiscal largesse, day treatment programs, case management, and intensive outpatient treatment were more abundant, but now suffer from a lack of funding, workforce training, or implementation. Newer models that integrate mental health care into primary care settings are becoming more popular but also need further development, workforce training, and implementation. Inpatient mental health clinicians stand at a precipice that divides intensive inpatient therapy (no longer necessary) from outpatient follow-up a week later (unlikely to happen). Today, they watch helplessly as Jennifer J. skips across the street in thin air to the bus stop while they hold tightly to the hope that this discharge will be different from the last three.  

To finally reduce costs, to improve outcomes, or to really help individuals get traction in their lives, we must create a fully accessible spectrum of services that can engage patients and offer alternatives to police, handcuffs, restraints, and haloperidol in an ER or the county jail. We don’t need more inpatient beds. We don’t need more ERs. We need smarter use of a broader spectrum of resources coupled with engaged patients who have access to them.

Let’s make that happen.

*Names and details of these events have been changed to protect anonymity of those involved.