Lynn Nanos Guest Post: Revolving Door of the Mental Health System

Thank you, Lynn Nanos, LICSW, author of Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, for this guest post.

Can We Slow the Revolving Door of the Mental Health System?
“When hospitals release seriously mentally ill patients too soon without outpatient follow-up, the patients can end up homeless, jailed, harming others, or even dead.”
— Lynn Nanos, LICSW

As a mobile emergency psychiatric social worker in Massachusetts, I evaluate many patients who have learned that getting psychiatrically hospitalized is more likely when they don’t take their medication and attend psychotherapy sessions. Too many patients are repeatedly readmitted to emergency services before inpatient is secured, despite that they needed this level of care months ago. Among those whose treatment implementation was delayed because they were not transferred from emergency services to inpatient care when this was needed, would they have become stable sooner if inpatient access was not delayed? For those who were repeatedly admitted to inpatient, could this have been prevented if they were discharged at the appropriate time? 

As a mobile emergency psychiatric social worker in Massachusetts, I evaluate many patients who have learned that getting psychiatrically hospitalized is more likely when they don’t take their medication and attend psychotherapy sessions. Too many patients are repeatedly readmitted to emergency services before inpatient is secured, despite that they needed this level of care months ago. Among those whose treatment implementation was delayed because they were not transferred from emergency services to inpatient care when this was needed, would they have become stable sooner if inpatient access was not delayed? For those who were repeatedly admitted to inpatient, could this have been prevented if they were discharged at the appropriate time? 

Not encountering a couple of patients who I previously evaluated in any given week is rare. I describe the revolving door of the mental health system in my newly published book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry

Breakdown: A Clinician's Experience in a Broken System of Emergency Psychiatry by Lynn Nanos, L.I.C.S.W.

While the inpatient course lengths have declined since deinstitutionalization, the rate of readmission to inpatient units has increased.[1] The revolving door in the mental health system refers to the rapid cycling of admissions to and discharges from inpatient units and hospital emergency departments, jails, and prisons. It is common to see psychotic patients cycle through hospital emergency departments five times in less than two months before they are moved to inpatient units.

The nationwide shortage of inpatient beds creates a backlog of patients waiting excessively for placement in emergency departments. Many sources indicate that the number of inpatient beds has declined by approximately 96 percent since deinstitutionalization, despite the population increase.

If a patient who meets inpatient criteria is prone to violence, doesn’t want any help, has no health insurance, or is expected to present extremely challenging barriers to discharge from inpatient, the wait for an inpatient bed will be longer than average because inpatient units discriminate against patients with these characteristics. I evaluate a highly psychotic young man, Fred, age 32, at the hospital. He doesn’t want to be there and had been brought there by police officers after he threatened to assault his cousin. Due to his history of assaulting hospital staff members, no inpatient unit accepts him. Colleagues, including myself, consistently confirm he qualifies for inpatient daily. After a couple of weeks, the emergency physician discharges him to the streets. Did he receive any psychiatric help other than the interviews we employed? No. Would he continue to deteriorate and pose a risk of danger toward others because of his psychosis after discharge? Yes.

Involuntary hold law is especially needed for some patients who lack insight into being ill and dangerous. Like most states, Massachusetts’ involuntary hold law emphasizes the risk of imminent danger while neglecting to prevent danger. When I find that patients do not meet this stringent standard, there is usually no choice but to discharge them home or to the streets.

Craig, age 25, presents to emergency services with his mother, Vera. They have been living together for years and she knows him better than anyone else. Craig immediately reveals to me he has no interest to meet with me. Vera clearly pressed him to come. She urges me to use her written journal to get him hospitalized. It shows his deterioration in functioning over the last year. He has increasingly isolated himself socially from others, dropped out of college, often been found mumbling to himself when no one is around, and once in the last month told his mom that he planned to cut his wrist in a suicide attempt.

As I refer to the above-noted concerns reported by Craig’s mom, he acknowledges most of them but minimizes them. He is not psychotic and states he never hallucinated. Nor is he suicidal. He clarifies that he had told his mother he wanted to kill himself approximately two weeks ago in the context of an argument they were in. He stated this with much more intention to upset her than to die. He easily lists reasons to continue living – love for his mom, dog, and brother. He lists coping strategies that he plans on using. He doesn’t qualify for inpatient.

What could I offer to Craig? He does not qualify for a state-funded residential program because he has not been deemed eligible for state-funded care. Even if he were receiving state-funded care, a residential program would probably not be available to him because there aren’t enough. And the state would hypothetically not prioritize him because he is not homeless. He cannot fund a private residential program. Partial hospitalization programs (PHP) involve a daily series of structured group psychotherapy sessions and a chance to see a psychiatrist. But many insurance companies, including Craig’s, do not cover this level of care. If he were covered by the “correct” insurance, would he follow through with this? I cannot predict the future but would guess not. Massachusetts, fortunately, has Community Crisis Stabilization (CCS) units in all areas. People in crisis sleepover in CCSs for a few days, where they receive ongoing support, the structure of psychotherapy groups, individual psychotherapy, nursing, and psychopharmacology adjustments. Although it lacks the supervision possible on inpatient units, it helps thousands of people who don’t qualify for inpatient. But it is a voluntary level of care, which Craig is not interested in.

Solutions can be implemented to slow the revolving door. More inpatient beds are needed. Inpatient units that discriminate against the most challenging cases should be held legally accountable. Legislative changes are needed to enable professionals to invoke involuntary emergency and inpatient care with less difficulty. Treatment options for patients who are not finding basic outpatient treatment enough, but who don’t qualify for inpatient care have to be easily accessible.

Lynn Nanos, LICSW
LynnNanos.com


[1] Appleby, L., D. J. Luchins, P. N. Desai, R. D. Gibbons, P. G. Janicak, and R. Marks. “Length of Inpatient Stay and Recidivism Among Patients with Schizophrenia.” Psychiatric Services 47, no. 9 (1996): 985-90. doi:10.1176/ps.47.9.985; Appleby, L., P. N. Desai, D. J. Luchins, R. D. Gibbons, and D. R. Hedeker. “Length of Stay and Recidivism in Schizophrenia: A Study of Public Psychiatric Hospital Patients.” American Journal of Psychiatry 150, no. 1 (1993): 72-76. doi:10.1176/ajp.150.1.72.

Formatting My First Book

Kitt O'Malley Blogging for Bipolar Mental Health
Kitt O’Malley Blogging for Bipolar Mental Health Book Cover

Been busy formatting my first book for publication. Problem is that while formatting it for Kindle ebook publication, I made changes. I can’t resist editing…

So, my Scrivener project is different than my Word manuscript which is now different than what I formatted using Kindle Create.

Oh, well. Guess that’s why each published version gets it’s own ISBN (actually, Kindle ebook doesn’t require ISBN, but I did buy a bunch of ISBNs).

The versions will be different in small ways. Or, not so small. We’ll see if or when I get around to formatting the Amazon print version, and later the IngramSpark ebook and print versions for distribution to sellers other than Amazon.

Just realized my title changed since I filed my copyright. Oops! Turns out that using a URL in a book title is a no-no. The book cover looks pretty familiar to those who know my brand.

I’ll let you know when the ebook is live.


This Thursday and Friday I’m participating in NAMI Provider Education in preparation for the historic opening of Children’s Hospital of Orange County‘s (CHOC) pediatric psychiatric unit — the first inpatient psychiatric unit for children under age twelve in Orange County. The entire staff will attend the inservice, which is incredible. We expect sixty-three attendees. I’ll be serving on NAMI’s panel as the mental health provider with lived experience.

In the past, parents had to take their kids up to UCLA’s Neuropsychiatric Unit. At CHOC, parents can visit their kids in crisis 24/7. One parent can sleep in the room with their child, which is important for young children.

When our son was hospitalized for dehydration at CHOC in Mission Viejo, we took turns spending the night. CHOC treats kids and their families wonderfully.

Review: Birth of a New Brain #PostPartumBipolar

Birth of a New Brain: Healing from Postpartum Bipolar Disorder by Dyane Harwood. Foreword by Dr. Carol Henshaw.

Dyane Harwood thrilled me when she sent me an advance copy of her memoir, Birth of a New Brain: Healing from Postpartum Bipolar Disorder. (I pre-ordered it and was anxiously awaiting it’s October 2017 release.) Her memoir fills a much-needed niche in sharing the experience of bipolar disorder, peripartum onset (beginning during pregnancy or within four weeks after delivery).

With her friendly approachable writing style, her strong spirit shines throughout her memoir, even when describing the devastation of bipolar disorder. Her story shows how important it is to not give up. She had to undergo ECT and multiple medication trials to find what worked for her.

Dyane explains both the traumatic symptoms she experienced and technical psychiatric information clearly and accurately. She managed to inform and inspire me. Her book is well-researched and includes useful and informative resources throughout and in her appendices. She even includes me as a resource (I’m totally flattered).

I identify with Dyane’s experience as a mother diagnosed with bipolar disorder postpartum, for I too began hypomanic ramping when breastfeeding my son. Honestly, I began ramping during my pregnancy — which led to workaholism, overactivity, and then bed rest — but I wasn’t diagnosed until he was a toddler. My diagnosis of dysthymia, which I had since I was eighteen, changed to bipolar type II. Both Dyane and I had our worlds turned upside down by the onset of our illnesses. As I write, I’m almost brought to tears remembering that time.

Shortly after I began blogging in late 2013, I met Dyane Harwood through her personal blog — Birth of a New Brain: A Writer Healing from Postpartum Bipolar Disorder (Bipolar, Peripartum Onset), which you can find at proudlybipolar.wordpress.com. Meeting Dyane online made living with bipolar disorder easier. Her support and friendship has been instrumental in my personal mental health recovery.

Flight Back Home

Friday, July 15th

Last Saturday, the day after we returned from Oregon, my mother was psychiatrically hospitalized for the third time since her stroke last November. Yesterday morning, I met with the treatment team at her psychiatric hospital. They do not think she needs long-term psychiatric placement. They believe her memory care community is the best placement for her and that she’ll just likely need regular “tune-ups,” returning to the psychiatric hospital when she refuses to take medication and her mental health deteriorates.

Luckily my parents’ house sold, with escrow closing yesterday. This morning I met with a financial planner to invest the proceeds from the sale on behalf of my parents and schedule regular withdrawals to pay for their care. Long-term memory memory care is expensive.

OR Trip
Oregon was beautiful and offered a relaxing break.

Flight Back from PDX to SNA – July 8, 2016

Before returning our rental car at PDX, we stopped for gas. While making a pit-stop, I received a call from my mother’s memory care community which I let go to voicemail. Inopportune time to take the call, as my purse hung on the restroom door handle out of my reach, and I didn’t want to dribble, squat and waddle over to answer my phone. Instead, I’m sharing the impolite (and perhaps amusing) imagery that came to my mind as the phone rang (to temper the vulgarity of the scene, my ring tone is Take Five by Dave Brubeck – yes, I love jazz).

The voicemail confirmed that once again my mother refused to take her medication and threatened violence against the nursing staff at her memory care facility. Once again, time for psychiatric hospitalization. This is getting old. Really old.

I fear my mom may need long-term psychiatric placement. Locked psychiatric care 24/7. Do not know what is available. Time to reach out for help. Time to research geriatric psychiatric residential placement for mom. Fuck.

That’s all I have to say on the matter. I do feel myself coming to tears. I fear, too, ending up like mom. Crap.

Shit.


Now I’m just spent. I did have a good time this week in Oregon. It was a nice break from my life, from my responsibilities, from the mess and clutter that is our house, from the mess and clutter that is my life.

We went to the wedding of one of our many nieces last night. They wed under Cathedral Bridge (St. John’s Bridge). The bridge is built with stunning Gothic arches and a backdrop of trees along the river. Then we had an incredible dinner at Plaza Del Toro. Very upscale and gourmet. So delicious. Loved it. Wish we had that kind of food in our neighborhood.

I look forward to getting away again and again and again. I need these breaks, these respites.