New safety standards aimed at limiting suicide risks have led to overhauls inside hospitals around the country, with psychiatric facilities and wards removing bathroom doors, stripping artwork from walls and requiring patients to wear paper gowns instead of their own clothes.
The changes have forced costly renovations and caused a backlash, with some critics contending they've made hospital rooms feel more like jail cells.
Regulators say the new guidelines leave room to protect patient dignity and privacy, but many hospital officials tasked with updating facilities and their procedures say they've gone too far.
"I think we are moving toward a very prison-like system," said Patricia Rehmer, president of the Behavioral Health Network for Hartford HealthCare, which operates Hartford Hospital. "We try and make it comfortable, we try and have as many things available as we can, but it's not easy."
New suicide prevention requirements took effect on July 1 on orders of The Joint Commission, an agency that works with the CMS and accredits the vast majority of the country's psychiatric hospitals.
A 2018 report by The Joint Commission Journal on Quality and Patient Safety found an estimated 49 to 65 hospital suicides happen annually. The report was described as the first data-driven estimate of inpatient suicides per year in hospitals.
In general, now pictures cannot be hung on walls, doors on bathrooms are either removed or replaced with polystyrene foam doors, and remotes are removed for televisions that are now secured behind plastic glass. Ceiling tiles and door handles must be replaced with risk-resistant ones along with special types of beds and sheets.
"We're buying the same furniture and plumbing fixtures as prisons and jails," said Dr. Bruce Schwartz, president of the American Psychiatric Association, adding that the requirements are creating harsher environments in psychiatric facilities.
Several organizations with the Michigan Health and Hospital Association have struggled to comply with the new requirements in the timeframe expected by The Joint Commission, said Laura Appel, the association's senior vice president and chief innovation officer. She said empty rooms may be safer but they're also significantly less comfortable.
"The lack of doors means an insult to patient privacy," she said.
Mental health advocates have raised concerns that less comfortable environments for patients could be less healthy.
Michaela Fissel, executive director of Advocacy Unlimited, said hospitals could make the settings more homelike and comfortable by adding yoga or music and letting patients wear their own clothes instead of a paper garment.
One patient, Cheyenne Wilson, said she felt as though she were in solitary confinement when she was admitted to Hartford Hospital's psychiatric unit for half a day when she was experiencing suicidal ideation. She said she had her belongings taken and searched and was told to get dressed in a paper garment.
"They took my clothes away and made me get dressed behind a curtain, not even in another room," she said.
Her father, Beresford Wilson, co-chairs the Connecticut Behavioral Health Partnership Oversight Council. He raised his daughter's experience at a September meeting and said it had too much of a punitive feeling.
"I think to make the experience as normal as possible when the person is under that distress, what they are looking for is normalcy as much as possible, not restriction or confinement," he said.
After her experience in the emergency unit, he said his daughter was given a therapy referral and has been taking classes to become a certified nurse assistant.
Dr. Charles Herrick, chair of psychiatry for the Western Connecticut Health Network, said the changes can make patients feel more depressed and can demoralize them.
"If you perceive the environment as a prison — and prisons are a place of punishment — then you can't help but think you are being punished, whether consciously or unconsciously," he said.
In response to criticism of the new guidelines, Joint Commission officials say they believe hospitals should be able to protect patient dignity and privacy while meeting safety standards.
"Balancing privacy and safety is always an important factor when caring for patients at-risk," the agency said in a prepared statement. "It is vital for organizations to develop procedures to ensure that individuals are regularly reassessed so the level of security/monitoring implemented is appropriate for the assessed level of risk."
The cost of renovating spaces and buying new equipment is another reason some hospitals have objected to the new requirements.
Partly citing such costs, two hospitals in Ohio and Wyoming closed their psychiatric units within the past couple of years. Officials from both hospitals declined to comment.
Thomas Jefferson University Hospital in Philadelphia had to remove bathroom doors in two-person rooms in its psychiatric ward, according to Dr. Kenneth Certa, a professor of psychiatry at the university's Sidney Kimmel Medical College. He said that meant removing one person from the room for privacy concerns and that decreases the number of people who can be helped at a given time.
Certa also said the hospital also had to purchase safety sensors for about 48 doors, costing $785,600 in total.
On average, the length of stay for psychiatric patients at a psychiatric facility is seven to 10 days, according to the American Psychiatric Association.
A movement away from institutionalization over the last half century has led to community-based mental health services replacing long stays in psychiatric hospitals. That same trend has also coincided with larger numbers of mentally ill people becoming homeless or incarcerated, where they receive little treatment — or none at all.