When all of the area psychiatric centers are full, as they often are, the emergency room at Carilion Roanoke Memorial Hospital becomes a holding cell of sorts for the mentally ill.
In recent months, as many as 12 mental patients at a time have been forced to wait in the emergency department — some for as long as three days — until a psychiatric bed becomes available, according to mental health officials.
Hospital officials say they have taken steps to reduce the numbers. But they acknowledge the difficulty of treating the injured and the ill along with the mentally ill, who sometimes arrive in handcuffs because of the potential threat they pose.
“It creates chaos, that’s for sure, and it can be very disturbing,” said Lyn Day, a Roanoke psychologist.
“Seeing someone bleeding to death is very disturbing for a paranoid schizophrenic, and hearing someone ranting and raving about the devil coming to get them is very disturbing for someone with a medical crisis.”
The problem is not unique to Roanoke. Across the country, as more people seek help from a mental health system that lacks sufficient resources to treat them, hospital emergency rooms are often forced to catch the overflow.
“It’s inhumane,” said Phyllis Scruggs, president of the Roanoke Valley chapter of the National Alliance on Mental Illness.
“Without being able to place them and have them receive treatment, you stand the risk of someone hurting someone in the emergency room, and you stand the risk of them running and escaping.”
Dr. Mark Kilgus, chairman of Carilion’s department of psychiatry and behavioral medicine, said he was not aware of any serious incidents at the hospital caused by the backlog of mental health patients.
But the risk remains as long as there’s a shortage of psychiatric beds, said John Snook, an attorney with the Treatment Advocacy Center, a mental health nonprofit group.
“It’s simply asking for trouble,” Snook said.
No beds available
In the ideal world, someone who comes to the emergency room with mental problems severe enough for inpatient treatment would be sent to one of the three psychiatric hospitals that serve the Roanoke Valley: private facilities operated by Carilion and Lewis-Gale Medical Center in Salem and the state-run Catawba Hospital.
In the real world, however, the combined 136 beds at the three hospitals are frequently taken.
“It’s not terribly unusual, particularly on Mondays, for us to have people waiting in the Roanoke Memorial emergency room to be transferred to a psychiatric bed,” said Gail Burruss, director of adult clinical services for Blue Ridge Behavioral Healthcare, the agency that provides community-based mental health care to the Roanoke Valley.
“Sometimes, they have been there since Friday.”
On a few occasions, as many as 12 mental health patients have accumulated, spilling out of a psychiatric room that can only hold eight people and into the general ER population.
“You’re dealing with the extreme there, but that’s not acceptable,” Kilgus said. A 72-hour wait for a bed is also an extreme, he added.
The problem was at its worst from January to June, Kilgus said, when one of the psychologists at Carilion’s psychiatric hospital became ill and could not work. The number of available beds was reduced from 32 to 24 to accommodate the staffing shortage.
As a result, the hospital was often at capacity. In the month of May, for example, there were no beds available for 26 of the 31 days, Kilgus said.
The facility is back up to 32 beds and the typical backlog in the emergency room is down to just a few patients, Kilgus said.
Still, hospital officials acknowledge the difficulties posed whenever a mental health patient who needs a secure bed cannot be placed immediately.
“It’s a definite challenge,” Kilgus said. “We’d love to effectively deal with these issues quickly.”
The number of people seeking emergency psychiatric care in the Roanoke Valley has increased by 27 percent in recent years, from 2,339 in 2002 to 2,971 last year, according to Blue Ridge Behavioral Healthcare.
Some worry that with the steady decrease in public and private psychiatric beds in Virginia and across the nation over the past few decades, the problem is far from solved.
“Everybody wants to put the mental health issues on the back burner, and I think that’s why we are where we are,” Scruggs said.
State funding lacking
Far from the often-chaotic scene of Roanoke Memorial’s emergency room, Catawba Hospital sits amid meadows and wooded slopes in North Roanoke County off Virginia 311.
The sense of solitude extends to part of the hospital: the seventh floor, which holds 40 empty beds. There is space at Catawba for more patients, but no state funds for the extra staff needed to care for them.
Jack Wood, the chief executive officer at Catawba, said he has unsuccessfully sought funding to increase capacity at the state hospital. Of the 110 beds at Catawba, 30 are designated for long-term geriatric patients and another 30 for elderly patients with immediate needs.
When Wood came to the hospital in 1991, it was operating with 218 beds.
But Catawba, like other mental hospitals in Virginia and across the country, has been seeing fewer patients over the past few decades as part of a trend to move more of the mentally ill into community-based programs.
The average daily population in state psychiatric facilities has gone from 3,260 two decades ago to 1,490 last year, according to figures from the state Department of Mental Health, Mental Retardation and Substance Abuse Services.
Wood has no argument with deinstitutionalization. But with Catawba and every other state mental hospital operating at full capacity, he wonders if there should be additional state funding to eliminate backlogs such as the one at Roanoke Memorial.
Virginia ranks 30th in the nation for the amount it spends per capita on mental health treatment, according to the National Alliance on Mental Illness, which last year gave the state a D as part of its national grading system.
While few dispute the need for more funding, there is debate about how the money should be spent.
Cutbacks at the local level have resulted in waiting times of as long as 27 days for an appointment with the community services board, said Bill Farrington, president of the state NAMI chapter.
To Farrington and Kilgus, the best way to prevent backlogs in the emergency room is to spend more money at the front end on community-based treatment.
“If we don’t do it quickly enough, then it’s turn the lights back on at Catawba and start using the beds that have been mothballed,” Farrington said. “But I don’t think that’s the correct solution.”
That’s also the view of Del. Phil Hamilton, R-Newport News. Hamilton is chairman of the House Health, Welfare and Institutions Committee, which is examining the state’s mental health system in the wake of the April mass shooting at Virginia Tech by a mentally unstable student.
Hamilton wants the state to invest more money in crisis stabilization centers like the seven that were recently opened, one in the Roanoke Valley. The facilities typically hold up to eight people who usually require just a day or two of inpatient treatment before they are placed in a community-based program.
Mental health advocates who have long pushed for two things — attention and money — say they are finally finding an audience in the General Assembly.
“I have been an advocate for mental health issues for years and years and years,” Hamilton said. “Now, it seems that everyone is a mental health advocate, and I think it’s a direct result of the Virginia Tech situation.”
Patient evaluations
Of the more than 700 people who went to Roanoke Valley emergency rooms for mental health care in April, May and June, about one in every four arrived in the back seat of a police cruiser.
Police can apprehend someone under an emergency custody order based on reports from family members or their own observations that someone might be a danger to themselves or others.
An official with the community services board — which in Roanoke is Blue Ridge Behavioral Healthcare — then evaluates the person. Those examinations usually take place in the emergency room at Roanoke Memorial, which receives the bulk of the cases because of its size and central location.
If further evaluation shows the person to be an imminent danger to himself or others, a magistrate can issue a temporary detention order. That leads to a hearing before a special justice, who must decide if the person should be committed.
But if there are no psychiatric beds available, the magistrate will not issue a temporary detention order, according to Burruss of Blue Ridge Behavioral Healthcare.
That, in turn, leaves many people languishing in the emergency room under an emergency custody order, which expires after four hours.
Sometimes authorities will buy another four hours by obtaining a second custody order. Other times, they simply hold the person with no legal authority, according to a report by the inspector general of the state Department of Mental Health, Mental Retardation and Substance Abuse Services.
“While not consistent with the Virginia code, both practices do assure the safety of a consumer whom the CSB [Community Services Board] has determined is in need of detention,” the study stated.
But if someone insists on leaving the hospital after his emergency custody order lapses, there’s no way to stop him. During a one-month period in 2005 that was the subject of the inspector general’s report, 37 people statewide were released against medical advice after the four hours ran out.
Snook, of the Treatment Advocacy Center, said most hospitals do all they can to keep a patient in the emergency room.
“They’re simply not going to allow them to fall apart, or kill themselves, just because there’s nothing that could be done in those four hours,” he said.
“People would much rather get in trouble for helping someone and keeping them in a safe environment rather than facing the question of why did you let someone go when everyone knew they were too sick?”
At Roanoke Memorial, handcuffs and locked doors are among the options for patients being held under a custody order. In January, a mentally ill man brought to the hospital under an emergency custody order broke free from security guards and ran. Pierre Carter ended up jumping into the nearby river and drowning.
Carilion spokesman Eric Earnhart said that because Carter had just arrived at the hospital, his escape was not related to the backlog of mental health patients in the emergency room.
Although some patients must be detained, officials opt for less restrictive means whenever possible.
“They’re not criminals in custody,” Earnhart said. “They’re patients who need help.”
‘A horrible situation’
What happens at Roanoke Memorial is also occurring at emergency rooms across the country.
In 2005, the nation’s hospitals handled 4 million emergency room visits by people with a primary diagnosis of a mental disorder, according to the Centers for Disease Control and Prevention. That represents 3.5 percent of all emergency visits — up from 2.7 percent in 1992.
“This is a horrible situation,” said Dr. Sandra Schneider, a New York physician and a board member of the American College of Emergency Physicians.
Most people who suffer mental illness “are not by their nature violent, but we’ve created a situation that can make them violent, or at least agitated,” she said.
At Roanoke Memorial, patients who need to be in a mental hospital get the next best thing: They are evaluated by the emergency department physician, given medication as needed and kept in separate quarters whenever possible.
While Roanoke Memorial has a room off the emergency department that can usually accommodate the mentally ill, about 90 percent of hospitals do not, Schneider said.
Some hospitals resort to issuing red gowns to mental health patients to distinguish them from the people who are being treated for heart attacks or broken limbs.
In Roanoke and elsewhere, mental heath patients with nowhere to go sometimes end up in facilities several hours away. And of the ones who end up committed to Carilion’s psychiatric center, about 30 percent come from more than 100 miles away, Kilgus said.
That can tie up the time of police officers, who end up transporting the patients.
In Alleghany County, which depends on Roanoke Valley facilities for inpatient hospitalization, Sheriff Dale Muterspaugh said his deputies spend several hundred hours a year shuttling the mentally ill around.
While state legislators have long known about the shortage of bed space in mental health facilities, “it keeps getting worse,” Muterspaugh said.
“The system has certainly bogged down and it seems like nobody is doing anything to address it,” he said. “There’s got to be a better way.”