New Crisis Unit Doesn't Meet Need For Acute Care, & ER Waits Are Intolerable, Says N.H. Psychiatrist

Mar 6, 2017

Not too long ago, New Hampshire was faulted for casting too wide a net when it came to institutionalizing people with mental illness.  That led to a lawsuit and a $30 million settlement, with the state agreeing to boost community-based care.

Now, though, according to Ken Norton, executive director of the NH chapter of the Alliance on Mental Illness, the state has swung too far in the other direction, with inadequate access to institutionalized care:

“We’re talking a pendulum swing here; 2,700 (beds), when we were at the peak of institutionalization, is an extreme,” Norton said on The Exchange.  “The 168 beds we’re at now is the other end of that extreme.  And it is not enough beds, and we need more beds.”

That’s 168 beds at the state’s psychiatric hospital, N.H. Hospital.  Last summer, the state opened an additional ten beds there but that has not made much of a dent in the need for acute care.  And that means patients are languishing in emergency rooms around the state -- with no place to go.

“We have seen the number of people waiting in the last two few months triple,” Norton said. “In April of 2016, we were averaging about 12 people per day waiting. And now we’ve been averaging over 40. Yesterday it was 46. The good news was most of last week there were zero children waiting. The numbers for children have tripled from just over one and a half to five or six on average per day.”

13 Days In A 12-by-12 Room  

John Dixon’s son Andrew suffers from a thought and mood disorder and has been admitted to N.H. Hospital twice.  Dixon says the care there was excellent. But getting there was the problem.  At one point, Andrew spent 13 days in an emergency room waiting for a bed.

“It was a trying time for him. It was an exceptionally trying time for me trying to support him.  He was in crisis and was receiving no treatment. And that to me is the most egregious part is that in an involuntary admission, he’s taken in, he’s identified as having a problem but receives no treatment during that time period where they’re waiting to get him treated. And it’s just very difficult for the patients. It’s very difficult for the loved ones.”

“He was in a 12-by-12 room in Frisbie Memorial Hospital, just waiting. They in essence take all your rights away, take your clothing away, give you hospital garb, put a guard outside your door, and have you just wait. And there’s really no treatment going on.”   

For Dr. William Torrey, a psychiatrist with Dartmouth-Hitchcock who also treats patients at N.H. Hospital, the situation is intolerable.  

“People who are acutely ill need care.  Imagine waiting 13 days if they had a serious cardiac illness or if they had a serious gastro intestinal illness. As a society we would not tolerate that at all. There would be an outcry. There’s starting to be an outcry. We need a solution to get people care quickly when they’re ill. Mental illnesses are diseases of the brain. How can we let people with these brain illnesses not get care?”

What’s Behind the Decline in Hospital Beds?

Over the years private hospitals have been closing their psychiatric units, in part because they are expensive, and reimbursement for psychiatric care is inadequate, said Torrey. 

But there’s another issue.

“To run a hospital you need to cover the unit 24 hours a day with a psychiatrist. And recruiting psychiatrists is incredibly challenging. I spend a lot of my time recruiting psychiatrists and this is an issue across the nation -- 55% of psychiatrists are 55 years of age or older. People are retiring. There is an increase in young people going into psychiatry now but it takes four years to train and in New Hampshire we have to bring them into the state as well.  I don’t go a week without five or six recruiters trying to recruit me and this is true for every psychiatrist everywhere.

Getting To Patients Before They Are In Crisis

Aaron Ginsburg is an attorney with the Disability Rights Center of N.H., which sued the state over its treatment of people with mental illness. At the time, the Center argued, too many people with mental illness were ending up unnecessarily in institutions.  Under a legal settlement reached in 2013, the state agreed to address the matter and improve community services.

Since then, Ginsburg says, the state has been working hard and has made progress, when it comes to community-based care -- investing in mobile crisis teams in Concord and Manchester, for instance, that intervene when someone is in crisis and can help avoid emergency room visits and hospital care.

Assertive Community Treatment (ACT) teams help stabilize people, he said. And supportive housing programs have also come a long way. "If you don’t have an apartment of your own it’s a lot harder to be stable. So these programs help people stay stable and avoid the crisis initially or maybe discharge a bit sooner.”  

Ginsburg says these programs are cost effective because they get federal matching money.   “You can do that way faster than bringing on a whole new facility or opening a whole new wing of an inpatient facility.”

Strategic Plan Needed

Still, despite state investments in mobile teams and assertive community treatment, directors of the Community Behavioral Health Centers said in a recent letter that the system is “on life support.”

Ken Norton says the state needs a strategic plan to address needs on both ends of the system -- community-based and hospital-based care.

“We’ve been operating as if the mental health settlement agreement is that strategic plan. And it’s definitely not. It’s very narrow in terms of its interpretation and what its proposed solutions are.”

As John Dixon sees it, the state is still reacting to the problem rather than getting ahead of it.  And people, like his son, still too easily fall through the cracks, which can seem more like chasms.  

“I’m not sure they know all that goes on. As an example, after my son’s first hospitalization, he came out of New Hampshire Hospital, he was still psychotic.  He chose not to interact with the community mental health system and for the next nine months did nothing and ended up back in New Hampshire Hospital because the state didn’t follow through with him; he didn’t follow through with the state… We talk about Assertive Community Treatment teams -- there was no such thing for him. He didn’t get involved in any of that. And they didn’t come to find him.”

Meanwhile, Dr. Torrey said, people like Andrew are extremely treatable. “When  people have access to the treatments that are known to work, that have been shown to be effective, people get better, and people can recover their lives and really get on with life.  All of us know lots of people with severe mental illnesses and we don’t know that they’re ill because they’re well. People really can do well.”

For audio of the full interview, as well as links to additional materials and  reporting on this topic by The Concord Monitor and NHPR, check here.  

For Exchange coverage of the struggle to find mental health workers in N.H., check here