Every day, mental health clinics, emergency departments, psychiatric hospitals, physicians’ offices, counselors’ offices, school counselors and police officers are faced with an almost impossible responsibility. It is a responsibility, a burden, often highlighted retrospectively, after a tragedy. Their job is this: identify every dangerous person, treat them properly and avoid horrific events like the recent murders in Tuscon.

I sympathize greatly, since I work in the emergency department of a hospital which has not one practicing psychiatrist, and no psychiatric ward. We aren’t alone. Many emergency departments in South Carolina, and around the country, have little access to mental health professionals. And funding for community mental health clinics has never been tighter in my memory.

Our facility is fortunate to have tele-psychiatry, which allows a kind of threat assessment by psychiatrists who are paid to be available for the service. We owe our telepsych capacity to a gracious grant from the Duke Endowment.

But not all facilities are so blessed. And indeed, even committed psychiatric hospitals and well-trained psychiatrists are in a difficult situation. The problem is so multi-faceted that I can barely put it into 750 words, but let me try.

The world has many troubled individuals. Some we recognize; many of them come to our family reunions, or work in the cubicle or office next to ours! Some of them are merely sad, some are tremendously angry. A number of them are psychotic, suffering from schizophrenia and other disorders of reality perception. A fair number of even those manage to work and function, though others become part of our tragic homeless population.

The problem is that sadness, or anger, or in some instances even hallucinations and delusions do not currently give us the legal freedom to force mental assessment or treatment on others. It can be done, but requires a detention order, signed by a judge; or the assessment of a licensed medical practitioner. It is no small effort, and requires law-enforcement involvement as well, to transport individuals for assessment, which will not necessarily result in commitment to a psychiatri hospital.

Obviously, there are those who are truly suicidal or homicidal. We all hope to interdict their actions, so that suffering and loss are avoided. However, many individuals think about, or verbalize, suicidal or homicidal thoughts, then recant. “I didn’t mean it…I was just angry.” We hold patients in hospitals for days and weeks over such statements, or the allegations of their families that they made such statements. We hold them against their willand are often faced with their attempts to escape, their rage, their frustration. Hosptials have to hire extra staff to watch them, one on one. Hospital rooms are occupied, waiting on mental health beds which are also occupied. And even in the best of situations, these patients often go through the same system over and over; frequently without actually harming themselves or anyone else. Others navigate their assessments despite genuine mental illness, because they are actually very intelligent and do an excellent job of hiding their thoughts and covering their pain and distrust. And yet, the ones not seen, not evaluated, not detained or treated, frequently kill themselves or others.

It is all about as clear as mud. I have seen persons with detailed suicide plans, or terrifying anger at others, who never so much as took an extra pill or nicked their wrists (or anyone else’s). I have also seen a patient’s family member, polite, well-composed and calm, walk out of the ER (never mentioning suicide), only to learn that they went straight home and committed suicide.

In very real ways, the evaluation of dangerous behavior is a search for a needle in a haystack. We have good guidelines, but the number of potential patients, factored with the number of those likely to commit violence against themselves or others, divided by limited resources, requires a calculation that inevitably fails to avert occasional tragedy. Not that we can’t try to do better; it’s just that the problem is titanic in scope; and never more evident than in the days and weeks after something like the killings committed by Jared Loughner in Tuscon.

Mental health is such a confusing topic. We often equate it with moral failure rather than with the neurological disease it typically is. And yet, sometimes we excuse evil with psychiatric diagnoses. Either way, we would do well to pay closer attention to those whose thoughts are disturbed; but also to show a little more mercy toward those who treat them in a thick fog of uncertainty, legal constraints and cultural stigmata.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

 

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