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Saturday, January 27, 2018

Evaluate, transfer, discharge. Repeat.

While the inpatient lengths of stay have declined since deinstitutionalization, the readmission rates to inpatient units have increased.* The revolving door in the mental health system refers to the rapid cycling of admissions and discharges to and from both inpatient units and hospital emergency departments, as well as to and from jails and prisons.
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A police officer escorts to my office a twenty-nine years old man, Owen. The officer explains that a psychotherapist's office called the police for assistance to have Owen removed from their agency because he was verbally aggressive and disruptive, refusing to leave. Apparently, he was there attempting to participate in an initial intake appointment to receive therapy and medication.

The hair on his head and face is long and matted. Even though the weather is warm outside, he is wearing three jackets. I look down and notice he's wearing only one shoe.

I cannot understand what he’s trying to convey because he rambles quickly and incoherently. Eventually, he tells me that he was referred to this intake appointment by a hospital emergency department. Besides telling me that he could benefit from some psychotherapy for his mania, he has no other concern and desires no other treatment.

He allows me to call his mom, Martha, so I do. She tells me that Owen has been functioning at the level I see today for the last four years, at which time she's been trying to get him help to no avail. "They keep on discharging him with nothing. They keep telling me he can't be helped unless he wants to be helped. He can go for weeks without sleeping. He has not even a cent to his name! The police usually bring him to the hospital. They call me, I beg them to keep him, but instead, they just let him go. It’s the same thing over and over again. He was diagnosed with bipolar and has been unmedicated for the last four years.” 

Owen is clearly unable to meet the ordinary demands of life. He is unable to attend to his basic biological needs. He is unable to maintain normal relationships. He is unable to communicate normally. I tell his mother about my intention to arrange for his hospitalization. To her relief, she agrees but cautions "He knows what to say to get out. They always believe him."

I try to find Owen with a plan to gauge if he'd be willing to go to the hospital. He is gone. I fax the involuntary authorization, with his mother's address on it, to the police. Hours later after completing an additional case, the police tell me they never found him. 

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A week later, I am walking in the hallway just outside my office, when I happen to see Owen speaking in a loud tone of voice, apparently arguing with a staff member.

"Is this the intake office for the outpatient department?" He still appears disoriented to the situation at hand, as he demands from me socks, shoes, a new apartment, and employment. I tell him that I cannot directly give these materials to him. Believing there is a moderate chance that he'll prematurely elope again from me, I quickly latch on to anything that could persuade him to allow me to interview him. I attempt to reassure him about my intentions to help him, by offering to help him investigate when and where his next outpatient appointment is, or if he even has one scheduled. 

He is more malodorous than he was last week. Following his train of thought is impossible. He is talking fast and excessively. I attempt to interrupt him numerous times to no avail, but he quickly interrupts me at every attempt. He is animated with restless body movements. He asks loudly, "What kind of fucking establishment are you running here? You're a joke," before vehemently listing the many reasons that I should have never been granted a master's degree. 

He mindlessly repeats my verbalizations. As I increasingly write notes, his agitation increases. He demands to read everything I write because of his belief that I'm writing lies about him. I stop writing. In the briefest silence imaginable surrounding his garrulousness, I ask if he hears any voice that may not sound real. He yells, "No!" Seemingly fifteen minutes later, he voicelessly utters words for a couple of seconds.

I offer him water and suggest that we briefly break so that I can consult with colleagues for advice. We agree to part, and he accepts water from me. I ask a colleague to watch him while I write up the involuntary hold out of his view, suspecting that he would likely elope if he sees me writing it. I fax it to the police. Almost whispering to prevent Owen from hearing me, I call the police and ask for their assistance. When I go to check on Owen, he is nowhere in sight.

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A month later, I reassess him. Seeing patients with psychosis cycle through emergency departments repeatedly within months before they are moved on to inpatient units is expected.

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*Appleby, L., et al. “Length of Inpatient Stay and Recidivism among Patients with Schizophrenia.” Psychiatric Services, vol. 47, no. 9, 1996, pp. 985–990, doi:10.1176/ps.47.9.985.; Appleby, L., et al. “Length of Stay and Recidivism in Schizophrenia: a Study of Public Psychiatric Hospital Patients.” American Journal of Psychiatry, vol. 150, no. 1, 1993, pp. 72–76, doi:10.1176/ajp.150.1.72.