Ruling could spur action to address psychiatric boarding crisis

Experts hope the recent ruling by Washington state's Supreme Court prohibiting the holding of psychiatric patients in hospital emergency departments while they wait for admission to a certified mental-health facility will prompt policymakers nationwide to address this pervasive problem.

In its Aug. 7 decision, the court said the state's involuntary treatment act does not allow for the boarding of psychiatric patients in EDs and other hospital units that are not certified to evaluate or treat them. The state initially had until Aug. 27 to move patients out of unauthorized areas, but that action was delayed while the court considered a motion to delay its decision for 120 days to allow the state to implement its plan.

Many hospitals around the country have been forced to keep psychiatric patients in what they widely recognize are unsuitable settings because of the lack of available beds at authorized-care facilities. Psychiatric boarding has increased as state and local mental-health budgets have shrunk. In addition to quality-of-care issues, boarding creates problems for hospitals because holding psychiatric patients delays treating other patients, reduces revenue, and creates security and safety issues for patients and staff.

Under the Washington law that the court found invalid, a patient can be committed initially for up to 72 hours at an evaluation and treatment facility, but could remain in custody for as long as 180 days, based on the severity of their illness and the threat they may pose to themselves or others. Patients needing longer involuntary commitment often wait in EDs from a few days to as long as a few months until they are placed.

A spokeswoman for the Washington State Hospital Association said her group hopes the ruling will spur broader use of tele-psychiatry services and greater investment in community-based mental-health services to identify and help people with psychiatric problems before they need emergency care.

While the Washington ruling has helped highlight the psychiatric boarding crisis, challenges to other states' laws that allow psychiatric boarding are unlikely, said John Snook of the Arlington, Va.-based Treatment Advocacy Center. That's because the court ruled only on a specific provision of Washington's involuntary treatment law requiring patients to be held in a certified mental health facility, which is unique to the state. That limits its applicability to other states.

But John Head, a spokesman for the Judge David L. Bazelon Center for Mental Health Law in Washington, D.C., said the decision could be cited in legal challenges to similar laws in other states. “Once a state involuntarily commits someone, they become responsible for the care of that person, and that care includes providing treatment,” he said. “Involuntary commitment without treatment is not really involuntary commitment.”

Nationally, there were 43,318 “public” psychiatric beds in 2010 compared with 50,509 in 2005, according to a 2012 Treatment Advocacy Center report. Thirteen states closed 25% or more of their beds from 2005 to 2010, and some of those states closed nearly half their beds. Nationwide, closures reduced the number of beds available in all 50 states to 28% of the number considered necessary for minimally adequate inpatient psychiatric services, which is 50 beds per 100,000 population. And many additional beds have been eliminated since 2010, bringing the estimated current total to 38,847.

A survey of more than 6,000 EDs nationwide presented at a March 2012 congressional briefing by the National Association of State Mental Health Program Directors found that 70% reported boarding psychiatric patients for hours or days—and 10% boarded patients for several weeks.

In Washington state, the number of certified psychiatric beds declined by 36% between 2000 and 2010. “Every time they closed inpatient beds, it wasn't that they were returning the people to the communities,” said Dr. Stephen Anderson, an emergency physician at MultiCare Auburn Medical Center near Seattle. “They were sticking them into the emergency departments.” One day last month, eight of Auburn's 25 ED beds were occupied by psychiatric boarders.

Last week, the state's Department of Social and Health Services announced it would spend up to $30 million to expand psychiatric bed capacity for 200 patients who are being boarded in Washington hospital EDs. About 50 beds would be made available within the next 20 days and another 95 would be ready within 120 days.

While experts see the state's plan to fund additional beds as an important step, some advocates have warned that hospitals could end up discharging mentally ill patients without evaluating or treating them.

But Anderson dismissed that possibility. “That's not going to happen,” he said. “Nobody at this point is going to be dumped back onto the street.”

Follow Steven Ross Johnson on Twitter: @MHsjohnson