 Welcome to the first health policy and bioethics consortium of the school year. Today we're going to be talking about mental health care and some of the intersections between health care delivery and policy and ethics and law. I think we're in for a real treat for today. My name is Aaron Kesselheim. I'm a professor of medicine at Greenwoods Hospital and a faculty member here at the Center for Bioethics as well. Myself and Lea Rand are the co-organizers of this consortium series. I will let Lea introduce herself in a minute, but if you want to just to sort of set a few ground rules this will last about 90 minutes. There is a Q&A feature you can find at the bottom of your screen. This year you'll notice we've learned how to use animation in our slides. So we've got a Q&A feature at the bottom of the screen. Please enter your questions in the Q&A feature at any point during the conversation. After our experts have their initial comments our moderator will use that to help launch the discussion. Again go back one. We're going to be tweeting at if you want to tweet at all you can tweet at hashtag policy ethics or at hashtag HMS bioethics. If there's any technical issues use the chat feature and I will pass it along to Lea because it appears that that's what the computer wants me to do. So Lea why don't you tell us about the consortium objectives and a little bit more about today's conversation. Thank you Aaron and now we know to watch out for PowerPoints with animations. My name is Lea Rand. I work with Aaron at the program on regulation therapeutics and law and I'm also a faculty member at the Center for Bioethics. And the aim of this consortium is to bring together experts with different perspectives on a current health policy issue so that we can explore the ethical implications of it and potential policy solutions and the aim really is to simulate further conversation and discussion. So we hope that you will be submitting questions and we look forward to this engaging conversation. It is my pleasure to introduce today's moderator. Nope first I'm going to remind you that we have our future consortium coming up in October. We will be discussing exceptions from informed consent research with Kerry Sims and Neil Dickert and in December we'll be discussing the World Health Organization's essential medicines list. So for today it is my pleasure to start us off by introducing our moderator Benjamin Barski. Benjamin Barski is a candidate in health policy at Harvard University. He is also an initiative fellow at Harvard's Edmund and Lilly Software Center for Ethics and Legal Research and a fellow at the University of Pennsylvania's scattered good program for applied ethics of behavioral health care. Ben's research sits at the intersection of health law and justice, mental health policy and disability rights. Before pursuing his doctoral studies Ben clerked for a federal judge in Memphis, Tennessee and held multiple positions in law and mental health policy. So thank you for leading our conversation today and I'm going to turn it over to you. Wow thank you so much Leah for the kind introduction and thank you so much Erin for everything here and happy September and beginning of classes to all students here. I'm grateful to have the chance to moderate this important and timely event. I began learning about inpatient psychiatry and what it means to operate within psychiatric institutions through my brother who many years ago worked as a pre-doctoral intern at Angkorah psychiatric hospital a 600 bed adult inpatient facility located in central New Jersey. We never talked about his individual patients but we did talk about the differences in the patients he saw a subject that goes to the very heart of today's conversation. What do we mean when we talk of inpatient psychiatry? And how is inpatient psychiatry distinct from or similar to other forms of behavioral health care? Many word Angkorah essentially as residents institutionalized for a long time due to complex needs. Others came through the criminal legal system including those found incompetent quote unquote to proceed with formal legal proceedings. Still others including those institutionalized against their will under civil commitment statutes were there temporarily. These complex differences are relevant for many standpoints clinical ethical and legal. How can clinicians provide patient-centric culturally sensitive care to people with different needs and backgrounds especially when resources are limited and laws and policies point in different directions? Our panelists well I'll introduce in a moment will provide invaluable insights on this question and they'll help us work through the many disciplinary problems that affect everyday inpatient psychiatric care. For example from a clinical standpoint we'll learn about the intersectional relevance of age, socio-demographic characteristics, comorbidities and disability status when caring for patients. We'll also learn about the delivery of care from the standpoint of institutions that is hospitals and other settings where patients receive inpatient psychiatric care. From an ethical standpoint we'll learn about how to apply foundational principles respect for autonomy, beneficence, justice and difficult and complex cases. Inpatient psychiatry has long behaved as though it is insulated from such ethical demands but we'll learn that things are changing although perhaps slowly and haphazardly. From a legal standpoint we'll learn about how statutes and doctrine have transformed inpatient psychiatry including through the immensely important deinstitutionalization movement that began around the middle of the 20th century. Along the way we'll question how to balance individual rights including those of self-determination and living in the community with clinical judgment and best practices. We must also acknowledge another element here. The COVID-19 pandemic has persisted ferociously since March of 2020. Congregate settings such as psychiatric institutions along with others such as nursing homes, jails and prisons have been battered by the virus infecting and killing tens of thousands in its wake. It's one of the deepest most horrible tragedies that we've suffered through in a long long time. We'll have the chance to learn about how COVID-19 has affected the delivery of psychiatric care and institutional settings. Along the way I'd motivate all of us to ask the following question. How could we have built a better more humane and resilient system in light of our individual and communal experiences during the pandemic? In other words, what is missing for this system to be one that is truly just, patient-centric and responsive to the lived experience of those who have or who will receive institutional mental health care? On this note, I'll turn to our amazing guests and panelists for the day whom I'm very grateful to introduce. The first is Susan Shilevsky who completed her psychiatry residency at the Alpert Medical School of Brown University general psychiatry training program and started her career there with an interest in emergency psychiatry, diagnostic evaluation and crisis stabilization. It's in this setting as chief of psychiatric emergency services that she took particular interest in advancing initiatives related to improving patient access to psychiatric care as well as addressing system issues. She serves now as the associate chief medical officer of McLean Hospital as well as in a Massachusetts general Brigham system-wide role, medical director of inpatient psychiatry. She's actively leading a new initiative to develop a coordinated centralized access center across MGB to better align individualized patient needs with available beds and services within the system. Dr. Shilevsky will be presenting with Dr. Jennifer Getz. Dr. Getz is double board certified in general psychiatry and child and adolescent psychiatry. She completed her internship in pediatrics at Massachusetts general hospital and her general psychiatry and child adolescent psychiatry training at MGH and McLean where she also served as administrative chief president. She moved to Baltimore and served as medical director of the child and adolescent inpatient unit at Johns Hopkins hospital. During her time at Hopkins she helped run the eating disorder clinical service, was an associate program director of the child and adolescent psychiatry fellowship program and co-directed the medical student course in psychiatry. She recently located back to the Boston area. Welcome back. And is an attending psychiatrist on various inpatient units at McLean hospital and an instructor in psychiatry at Harvard medical school. Finally, Dominic Sisti, Dr. Sisti, a longtime friend and colleague is an associate professor in the department of medical ethics health policy at the University of Pennsylvania. He directs the scatter group program for the applied ethics of behavioral health care and holds secondary appointments in the department of psychiatry where he directs the ethics curriculum and the residency program and the department of philosophy. Dr. Sisti examines ethical and policy challenges in mental health care including long-term psychiatric care for individuals with serious mental illness and clinical ethics issues in correctional settings. His research also explores ethical issues in psychedelic research and clinical application. Dr. Sisti's writings have appeared in medical and bioethical journals such as JAMA, JAMA psychiatry and in popular media outlets such as the New York Times, the Economist, NPR, the Philadelphia Enquirer Slate and the Atlantic. He is co-editor of three books including applied ethics in mental health care an interdisciplinary reader published with MIT Press in 2013. With great pleasure Susan and Jen I'll now turn it to you. Great, thank you Benjamin for such an incredible kickoff and introduction and a special thanks to all of the organizers of this consortium for bringing this important topic forward. We really appreciate it and are so happy to be here. I am particularly happy to be sharing the stage with the other discussants today and Dr. Gatz and I will kick off starting with a little bit of a clinical perspective on inpatient psychiatric treatment with a focus on boarding beds and bioethics. Next slide. So what we hope to cover in our talk today is just a general overview of some of the framing components of what's been leading to this problem and then move into some more clinical examples with some case examples and drivers with ethical considerations and then maybe wrap it up with some advocacy and potential solutions. Next slide. So to set the stage for everyone we want to share some of the general mental health statistics that exist. So within the United States alone one out of every five adults and one out of every six youth experience mental illness. One out of 20 experienced serious mental illness with 12 plus million people having serious thoughts of suicide and suicide being the second leading cause of death among individuals age 10 to 34. Next slide. So having that context we are struggling now really with what is being defined as a behavioral health crisis and the theory behind that really lies within our ability to match the demand to capacity. And so in 2020 there were 12,275 registered mental health treatment facilities. Of those 9,634 were ambulatory or less than 24-hour services and only 1,800 were inpatient services. That kind of translates to about 35,000 beds in service psychiatric beds available within the United States which is 11 beds per 100,000 of the population. The estimated and most cited metric around the psychiatric need is somewhere near 40 to 60 beds per 100,000. With this consideration and in the graphic on the other side of the slide on the right hand side you could see some of the impacts that we've seen over the past couple of years in relation to the COVID-19 pandemic. And what you'll really see is a rising behavioral health and acuity need. So this existed even pre-pandemic but it's been elevating up with a decline in overall workforce in a pretty static long-standing under reimbursement for services. And that coupled with the rising mental health illness so when we looked at statistics of the marker for what the need is for inpatient psych services it's defined as serious psychiatric distress. That rose from 4% in 2018 to 13% in 2020. And you know the other consideration to keep is pre-pandemic one of the largest factors for blocked beds or beds unavailable within the system was acuity or severity of patient presentation. Now it is truly the workforce shortage. It is the single largest cause for beds being made unavailable across the system. Next slide. So what does this mean for Massachusetts? You know it is a nationwide problem of the behavioral health crisis but this really translates to about 540 behavioral health patients awaiting placement in emergency departments across our state today. Many of the drivers of that are thought to be not enough beds for demand, higher patient acuity and medical complexity, the workforce shortage, so risk gaps and payor mix. Next slide. Thank you so much Dr. Slavki. I'm also really excited to be here and to present a little bit of the clinical lens and some of the day-to-day issues that come up that intersect the ethical and legal domains regarding inpatient and psychiatric care. So to start off I want to walk you through a kind of a typical patient experience who might be seeking inpatient care. So I've changed the names and a few of the identifying details on all of these cases to protect patient identity but we'll start with a female named Patricia, 52-year-old lady with a history of bipolar disorder living with her life previously with employee but over the last couple of years has not been able to work. She has a history of multiple priors that be after hospitalizations prior to the initiation of lithium, a mood stabilizing agent over 15 years ago. She had over 10 suicide attempts of very high lethality and over the last year had developed lithium-induced nephropathy or stage 3 kidney disease for which her lithium was stopped and she had actually become quite unstable since that time and presented in the emergency room status post-suicide attempts, increasing agitation and dysregulated disease here. So thinking through that case, I want to go into a little bit of background information about how patients actually get to a psychiatric bed and what inpatient psychiatric care actually is. So the most common pathway to an inpatient psychiatric bed is actually through the emergency department. When patients arrive to the emergency department they're typically seen by an emergency medicine condition and then deemed to need a psychiatric evaluation and that evaluation can take place by a social worker, an MD, an ARMP, or a PA. And patients sort of based on their symptoms and presentation are then deemed to sort of meet the threshold for an inpatient level of care. And the inpatient psychiatric unit is kind of equivalent to the medical intensive care unit. It's literally the highest level of care that exists in the behavioral health world and only folks with the most sort of severe illness or symptoms really requires like inpatient psychiatric care. And because we're talking about illnesses that affect the mind and at times decision-making insight and judgment, there are two sort of pathways to the inpatient unit either voluntarily or involuntarily and I'll get into a little bit more of that in a couple of minutes. Once patients are deemed to require an inpatient bed something called a bed search begin and this process can actually take at best a couple of hours and it works a couple of months depending on a variety of factors that we'll get into in a few minutes. During this time patients do what's called boarding in the emergency room. So once they once it's been determined that they require an inpatient psychiatric bed they kind of sit in the emergency room waiting until they secure a bed. Once a bed is available someone has to obtain insurance authorization so unlike in a medical admission when patients are able to just go up to the medical floor when the doctor says they need to be hospitalized. Psychiatric patients actually actually have to get prior authorization through their insurance in order to be admitted. After that routine patients are able to be transferred to an inpatient psychiatric facility for care and treatment where the average length of stay is about seven to ten days with a quite a considerable amount of variation. Unlike general medical hospital inpatient psychiatric hospital exists in a couple of different places so sometimes they're part of the general medical hospital like a ward or a floor embedded within a major medical center times psychiatric care is actually delivered at free standing psychiatric hospitals and these can be private or these can be public and they can be for-profit or they can be non-profit organizations and so there's added layers of complexity when it comes to insurance authorization and who's able to go to what type of a bed and for what purposes. In inpatient psychiatric unit as I alluded to before is the highest level of care that we offer in psychiatry it's the intensive care unit of behavioral health care and patients can be admitted because they are at least willing to accept care even if it's under direct or coercion or involuntarily which is when they're sort of adamantly against being in the hospital and refuse to do something called signing in which essentially means that they're willing to come into the hospital work with you and when patients come to the hospital involuntarily they're actually afforded certain other rights because that process then involves the court and the legal system through civil commitment procedure. The inpatient unit is a little bit of a different type of environment than a general medical floor where patients are generally just in their rooms focused on their their care they're not really aware of what's necessarily going on with the person in the bed next to them or the room next to them. The inpatient psychiatric unit is not just a place where patients stay overnight and get med changes it's actually a therapeutic milieu and a setting that is supposed to help with healing and recovery and to that end we offer multiple different sort of modalities that I'll get into in a few minutes but first and foremost we offer a safe and contained environment for individuals going through a mental health crisis. We perform thorough diagnostic assessments to sort of guide treatment and medication management as well as different therapeutic interventions and support and we also work really hard to help with the transition process outside of the hospital because we know that inside the hospital many stressors that often can exacerbate mental illness are removed and that when patients go back out into the world it's actually another quite vulnerable time and so we work very hard from day one on after care arrangement follow-up on different care transitions. While we're focused mostly on the inpatient sort of locked hospital intensive care unit level I wanted to highlight some of the less restrictive levels of care that are also available within the system and some of the issues with act up in them so in the middle we sort of have unlocked voluntary levels of care so these are units or programs that individuals can go to when there aren't acute safety concerns or patients are not too disorganized or unstable to take care of their basic needs. They tend not to have 24 hour nursing care though they do have 24 hour support and then the least restrictive of these programs are ambulatory type programs so these are programs that patients can go to during the day or for pieces of the day to get extra support and are often used as transitions out for transitions out of the hospital to sort of ease the landing if you will. One of the challenges and aspect in some of the less restrictive environments that may actually be appropriate for patients from emergency room setting is that they're actually quite challenging to affect in an emergency. Many of these programs don't have access points after certain hours of the day and patients come into the emergency room 24 hours a day. These programs often require patient participation in the intake process and so that's really challenging in an emergency room and many of these programs during the COVID pandemic actually shut down completely do a number of factors including staff shortages, challenges with cohorting patients and a number of other sort of issues. They come back some of them virtually and that's really challenging for a number of patients and so it's only the last couple of months that programs have really started to come back in an in-person way. So we always strive to send patients to the least restrictive environment possible when we're thinking about what level of care they're appropriate for but unfortunately from an emergency room setting oftentimes the path of use resistance when someone needs a higher level of care than being at home and just going to regular outpatient appointment. Inpatient often becomes the path of use resistance despite the fact that there are many levels of resistance that will pop up. So the three major categories of individuals that kind of reach the threshold for inpatient care are those that are a danger to themselves and this includes individuals who may be acutely suicidal or who have had a recent suicide attempt. Those that are a danger to others so I would really like to highlight here that while this is a potential avenue into an inpatient unit folks with mental illness are much more likely to be the victims of dangerous behavior and dangerous activity than they are to be the perpetrators and finally individuals who are unable to care for themselves so things like not attending to activities of daily living like brushing their teeth, eating, showering, toiletting, those types of things or exhibiting behavior in the community that is sort of inappropriate or not socially acceptable. Those are sort of the types of patients who reach the threshold for acquiring this intensive care unit level of hospitalization. In terms of what illnesses we treat essentially if it's a psychiatric illness we can treat it on an inpatient psychiatric unit. There is a caveat to that which is depending on the psychiatric facility some places are equipped to handle certain types of illnesses and comorbidity and some are not and the specific expertise or the specific types of interventions that are available actually depend on the facility and so patient unfortunately don't come in prescribed boxes that fit nicely all the time into the types of units that we have available and patients are often much more complicated and have more complicated needs than what we're often set up to address and so while we may have units specifically for mood disorders or psychotic disorders or substance use disorders or eating disorders the reality is that oftentimes these things coexist for patients along with medical conditions and when we become so sub-specialized we often make that on the ability to treat the whole individual and so sometimes illnesses specific illnesses can actually be limiting for individuals in terms of speaking care. In terms of how we treat patients on the inpatient unit there are sort of three main categories of treatments that patients get so daily assessments with psychiatry and social work is the primary sort of clinical intervention and this includes ongoing diagnostic assessment and formulation as we're always trying to think about what's going on for the patient right now and what does their illness look like over time. We're monitoring and treating target symptoms monitoring response to medication or continuously affecting safety working with families and other support systems and thinking about how to transition individual to the next level of care but the most best next least restrictive level of care. Inpatient units are kind of scaffolded on a group programming schedule and these groups vary certainly by unit and expertise but they tend to be focused on wellness and recovery peer support coping strategies for stressful situations resiliency and relapse prevention and one of the most powerful aspects of inpatient care is actually the the peer community that develops and how individuals going through mental illness are able to kind of support each other through these really challenging times it's really intense time that they're going through and then finally our milieu is a therapeutic modality in and of itself with a very high staff-to-patient ratio that's engaging it's therapeutic there's lots of activities to do that are relatively low stress and and minimally overstimulating to help patients kind of recenter and ground but one of the most important ingredients that we provide on the inpatient unit is caring and compassionate staff who are able to hold both our patients and families who may feel like they have nothing to hold on to during periods of crisis so I want to return to the typical case that I presented earlier and just update you a little bit on the hospital course because the patient was initially admitted involuntarily and then later signed in voluntarily she's restarted on lithium as well as some other medications and had a dramatic improvement in terms of her overall mobility aggression and suicidal plans her wife was involved daily in rounds for the patients request we did a lot of robust safety and crisis planning and we're able to coordinate aftercare with a new treatment team for her but that doesn't mean that everything went well and this is actually a very challenging consultation for the patient and for the clinical team overall the patient got better we were able to maintain her safety and kind of plan for future crises as best one can do we were able to coordinate aftercare and make sure that she was already followed in a robust way and we were able to monitor her medical parameters and work in very close coordination with her nephrologist the downside of for hospitalization was that because it was involuntarily initiated and what I mean by that is an outpatient psychiatrist actually called police and had the patient sent to the emergency room on what's called an involuntary evaluation paper it caused a real adversarial relationship from the very beginning not only with her outpatient team but with the inpatient team and she was in general quite mistrustful of staff and of the hospital and hospitals in general so this presents a little bit of an ethical dilemma so when thinking about the different ethical principles in this particular case I think there's three that sort of stand out the most and those are those of patient autonomy, beneficence and non-maleficence on the one hand the patient didn't want to be in the hospital and her autonomy was overridden with this involuntary admission for safety she initially actually was very against restarting lithium because of concerns about kidney damage. On the other hand we knew that the patient had had quite a lot of success with lithium and a long period of stability and that her risk of actually dying from self-inflicted injury versus her risk of dying from issues related to nephropathy from lithium were quite in favor of restarting lithium however we couldn't be sure that restarting it wouldn't cause further damage and do further harm. So should our clinical impression that we can improve functioning by restarting lithium in the best interest of the patient override her autonomous decision not to restart it knowing that it has already caused harm and may cause further harm and taking it one step further should she actually take up a bed in a system if she isn't agreeable to care a bed that could be allocated elsewhere thinking about the ethical principle of justice in a sparse resource environment. So I want to transition for a minute because that was actually a typical case just a regular Tuesday if you will and what happens when things are a little bit less typical. So I'm going to present to you a couple of cases and present to you a couple of sort of issues or dilemmas that these cases bring up and I'm hoping it'll generate some questions later on. So this is a patient who is 16 years old when I initially saw her with a history of developmental disability and intellectual impairment features of autism spectrum though never formally diagnosed and she had about a year period of worsening of pregnancy failure which had led to prolonged hospitalization and frequent aggressive behavior on the inpatient unit towards staff, peers and family which had actually led to prolonged isolation and frequent restraint. She was actually determined to need a level of care that is actually basically a state hospitalization and state hospitals are equipped to kind of bridge the gap between what a hospitalization used to be in terms of a longer length of stay with kind of transitioning back into the community in a more gradual way and so this patient waited months for a bed during which she actually continued to really struggle and decompensate partially owing to the prolonged length of stay which was greater than eight months. So the facts are that beds are a scarce resource as Dr. Shafi pointed out earlier we have about 11 beds per 100,000 and we need 40 to 60 so the numbers don't match the need. Higher patient complexity on the inpatient unit tends to lead to greater lengths of stay and reduced bed turnover so patients are in beds for longer periods of time which means that there's less ability for patients to get out of the emergency room and into those beds. These issues are actually even more pronounced for the child and adolescent population for which there are even less state beds available and less beds across the country and prolonged lengths of stay as in this case might not actually reflect ongoing need for inpatient level of care but might actually be related to inability to secure aftercare or for various services to come in and help kind of align the transition out of the hospital and so can we think about justice being a driver of care in situations like this and if we can how do we provide equitable access to a scarce resource and who's responsible for allocating these resources. These are questions that I think did come up in the COVID pandemic when we were thinking about having to ration ventilator use early on but we actually have to make decisions like this every day when we take one patient into an inpatient bed versus another so I want to talk a little bit about the case of medical complexity so this is a patient who had a very long history of bipolar disorder and lots of prior psychiatric hospitalizations and suicide attempts who was actually brought into the medical hospital in a coma following a nearly lethal ingestion of his medication followed by crashing of a car into a storefront in a suicide attempt. He was medically hospitalized for several weeks in the intensive care medical unit before he was medically stabilized and then waited several more weeks for an admission because hospitals were essentially afraid that they weren't able to take care of his medical needs on a psychiatric unit. So this brings up a couple of a couple of ethical issues along the doing what's best for the patient and not harming the patient so this particular patient while he awaited care in a medical bed he was in care he was he was safe he had a sitter in a one-to-one and he was meeting stemming regularly with the psychiatry mental health consultation liaison too so they were monitoring his psychiatric status and providing as needed medications and sort of maintaining the status quo awaiting in patients like the after hospitalization. However if we're thinking about doing no harm was was he actually being harmed sitting on the medical floor well his while he was being seen by a psych team he wasn't actually getting treatment he was just sort of getting evaluated um there was no therapeutic no you right he's in an individual room in an intensive care unit um with a stranger sitting next to him watching him he was unable to access needed ECT treatment for his underlying illness he wasn't given any psychoeducation his family wasn't involved he couldn't go outside he was sort of bedridden and so one could argue that this practice is actually harmful to patients and in this case this is a patient boarding on a medical floor rather than an emergency room setting but it's the same concept. And then finally I want to take a look at the case of a patient who have limited ambulatory resources in the community so this is a 36-year-old male homeless and unemployed with a history of mesoaffective disorder which is a combination of bipolar disorder and schizophrenia sort of as well as multiple substance use disorders primarily alcohol and cocaine with lots of prior hospitalizations and suicide attempts who had been repeatedly admitted over the course of several months of just back to that hospitalization um in the setting of getting discharged not having a place to stay or program to follow up with turning to substances um not being able to take his medication and not being able to have follow-up with providers. So um when this patient prevents to the emergency room he's too sick psychiatrically to access dual diagnosis treatment programs which are if you recall from an earlier slide a voluntary level of care so patients can't really get treated suicidal um and when he clears psychiatrically um dual diagnosis programs don't want to take him because of his history and so he falls in this trap where he's not able to stay sober and his psychiatric illness worsens um and he gets into a very vicious cycle. So um this particular patient is but one example of so many in our system who have no program or place to catch them. So as we talked about um demand for care doesn't always reflect the need and patients are often for a variety of reasons not able to keep care of traditional route whether it's the inaccessibility stigma not being aware of the need or they're just being new long wait times to steeples in the outpatient setting and then the emergency room becomes sort of the de facto care site though it's not really equipped to be a care provider. Patients are repeatedly hospitalized and can use beds with limited improvements because of limited or no aftercare options so the inpatient unit becomes the only consistent mental health care provider that many patients have and they cycle in and out of the hospital multiple times in a couple of months. And so the question arises should we be re-admitting patients with the same presentations over and over or did it contribute to over dependence on a system or mid-limited resource availability a sort of justice question and should we be thinking about who requires an intensive care unit level of care within the system and how we can take care of patients in other settings from a systems perspective. So when I was a resident and a fellow I think I felt the system and these issues the most because it wasn't unusual to be on the inpatient unit in the morning and the emergency room in the afternoon in the outpatient clinic in the evening and to really bounce between all of these places and you really see all these patients waiting in the emergency room and the pressure cooker that it is. And then you see patients coming to you in the outpatient clinic who have been waiting for months and months to get in and have gotten worse and worse during that time. And then you see patients on the inpatient unit who also struggle to get out of the hospital. So you see the bottlenecks and really feel the systemic issue I think the most when you're working in all of those settings at the same time which happened for me mostly in residency. We have a price-as-then-response model of care and we the results that we have are price-as-then-response results. We have not invested in individual renditions in their mental health care and we haven't invested in a system of mental health care that's able to take care of a population of individuals with a wide variety of mental health concerns. Many of the patients that we see on an inpatient unit can actually be taken care of in other settings but these other settings are inaccessible for a variety of reasons to most patients or to many patients. And so we haven't decided that we value taking care of the population and their mental health needs from a systems perspective quite yet although things that we're moving in that direction. And with that I'm going to hand it back to Dr. Schleffi. Great, thank you Jen. So as Dr. Getz and I started this conversation with a multifactorial problem in terms of solutions what we need is a multifactorial solution. And so as Dr. Getz illustrated in many of the case examples that she gave us is that there's no easy one-size-fits-all. This is not a math problem we're not going to solve it just by increasing our inpatient bed capacity alone. We nearly need to examine the effects of our fragmented system moving towards our integrated care thinking about what this means in terms of our community-based teams, our support network integration, boosting our mental health staffing with new innovative pipelines, reducing the continuum of care challenges that are creating these bottlenecks again as Dr. Getz illustrated very clearly through the cases she presented here today. And then looking to expand our preventative mental health care not just living in a crisis based solution, ensuring financial stability of the mental health units and facilities and advancing mental health parity. Next slide. So because we are psychiatrists we do like to always end on an optimistic note. So thinking in terms of advocacy we had kind of lived in limbo for quite a long time in terms of behavioral health. In Massachusetts in the last month alone there is some exciting advancement towards the legislation signing into law the Mental Health Act 2.0 addressing barriers to care and the goal of this is truly to get the care you need when you need it. There are many components of this it's a very long bill if people are interested I encourage you to go and look at it but some highlights from it is really this 400 million financial allocation towards rescue funding with a particular emphasis on new inpatient mental health, bed development, staff recruitment and retention, embedding behavioral clinicians in all of our emergency departments. We know at this point in the way the system is operating that this is often the first line for patients presenting for care. The creation of transparent open bed portals across the state reforming prior off requirements behavioral health is still one of the only medical specialties that require you to get a full insurance authorization before you can receive the sometimes life-saving treatment that patients need creating a standard release for the exchange of confidential information and generating equitable reimbursement so that we continue to keep the providers and caregivers in this field. Next slide. We just want to end this with a sincere thank you for the opportunity to be able to share our perspective here and we look forward to hearing Dr. Siste's talk next and engaging in some conversations and questions later. Thank you. Thank you so much Dr. Schlefsky and Dr. Guetz it was an amazing way to kick off this afternoon's session and thank you also for everybody in the audience for your questions. Keep them coming and we'll now turn to Dr. Siste's segment of the session. Thanks Ben. Thanks Dr. Guetz, Dr. Zaleski. Let me see if I can share my screen here. Hopefully you're not seeing my notes. Tell me if you are somebody but my talk basically is going to reiterate a few of the themes that you just heard Dr. Guetz in particular mention which is the idea that you know the system that we have in place right now is a product of choice so the priority setting or lack thereof really and you know the ethical ramifications of neglecting those hard decisions and funding a comprehensive mental health care system have led us to this crisis point. So I am Dr. Siste, I'm an associate professor at Penn and the title of my talk is bedless psychiatry building mental health service capacity. Just a few acknowledgments here and my disclosure I have no conflicts of interest. So really the you know the argument I want to make it's not really that super sophisticated doesn't really take a PhD in philosophy or anything that come up with this but it's just the idea that like anyone with serious mental illness like anyone with a serious medical condition individuals with serious mental illness deserve the treatment that they need at the appropriate time and in the appropriate setting and here we have an image of a young girl who's 13 her name is Melinda. She was boarded in a hospital emergency department for 17 days with suicidal behavior and panic. I think this was a Massachusetts hospital in fact and she was profiled her and her mom were interviewed by NPR about a year ago. The idea that an individual any age but oftentimes a minor is living like this inside an ED should strike us as as deeply troubling and problematic. Just a basic definition here what boarding means. The ED evaluation is done and it's time now to this to figure out where the patient's going to go. There's no work for the patient to get. So this is from the American College of Emergency Physicians. This is their definition of boarding. Patient is boarding if the patient's ED eval is complete and the decision has been made to either hospitalize or transfer the patient but there's no availability for various reasons. All this sort of abstraction in a way and this preamble to the American College of Emergency Physicians like white paper really sort of got me a little bit and I was reading it last night so I wanted to just share it with you. Imagine being depressed and suicidal and asked to lie in a stretcher in the middle of a busy ED perhaps surrounded by drunk and psychotic patients who also need to be under clinical security observation. Imagine being in the situation for days with no sunlight no exercise no good sleep no hot food and no one to begin to help you pull you out of your deepest spare that brought you to the hospital or imagine being psychotic already destabilized and disorganized in your relationship in the world and made to stay in the further destabilizing chaotic environment of the ED again with no sleep sunlight receiving only meds that primarily are intended to keep from acting out rather than being tailored to help control your symptoms. It's a nightmare scenario. Several years ago we a group three of us Dr. Steve Sharsteen who was at the time was at Shepherd Pratt Elizabeth Sinclair who's with the treatment advocacy center and I wrote a paper on the issue of bedless psychiatry and its you know ethical ramifications and you know basically you know we see the the the way individuals with serious mental illnesses are diverted to you know less optimal less ideal treatment spaces because of the capacity problem. You know oftentimes you know individuals are boarded in emergency departments that are gridlocked for days weeks or even months or they're treated which is just the idea that there's no room and they want to leave so you sort of just let them go. In fact one of the one of the reasons I sort of started thinking about this this challenge like 10 or so years ago was the residents at Penn were really morally distressed about treating and treating patients they didn't have anywhere to go so they had to they didn't know what to do they were treating patients and they brought it up time and time again as a really deeply troubling practice. Some nine violent individuals maybe get arrested and they're too poor to pay bail they're going to be incarcerated and that's another center of mental health boarding I'll talk about in a few minutes and then of course people just don't want to deal with the system they can't access it they don't have the energy that all the time and all the resources so there's uncounted individuals scores of people with serious mental illness living with sub par treatment or no treatment at all with their families and yeah it's just you know the idea of a comprehensive mental health care system I think is what we all agree we need we need a system that treats patients from you know of low you know low severity to severe patients with various stop points along the way from outpatient care to inpatient care. As Dr. Goetz was saying we you know it's not just about inpatient beds it's about every aspect of this continuum being well funded well staffed you know outcomes and evidence based and you know robust and it's just like we don't have really any of these part like I don't feel confident in any of these sort of nodes on the continuum we're in a real crisis there's gaps in between each of these that are probably wider than the actual pavement itself so you know the goal is to have a comprehensive mental health care system and for that you need all of these different components for kids it's even more complicated and this is just a table that's in a white paper by the American Academy of Child Mentalism psychiatry in a list you know in terms of increasing severity from top to bottom left to right the various stop points along a sort of high quality ethically constructed comprehensive mental health care system from outpatient clinics and intensive case management to family support systems and respite type services to therapeutic group homes and crisis residents residencies residential treatment facilities and of course hospital treatment so all of these things are equally important components on this continuum without all of them functioning effectively they all there's a cascading effect where you know patients will get bottlenecked in one place or be diverted to another and their outcomes will be less than ideal so you know boarding of patients is one thing that happens we're talking about here and you know leads to all sorts of bad outcomes from higher morbidity higher mortality obviously consuming ed resources that are you know oftentimes scarce if we're talking about the pandemic in particular causes ed overcrowding dissatisfaction with care by you know the patients are dissatisfied with their care of course the you know treatment milieu such as it is is disrupted and of course death are frustrated and experienced like anger moral distress counter-transference and you know maybe make more mistakes so it's just not a good situation for anyone this table here and these oh sorry this table here and some of these points I'm making or come they come from a paper that was recently published by a group from the University of North Carolina and you can see they did a little counting here and you can see the disposition of folks who were boarded in the ed is like 39 patients and 69 of them were sorry 27 or 69 of them were declined by all North Carolina acute inpatient hospitals so you know the challenges are are great here there's any number of reasons why that is it could have been as Dr. Zalowski was subscribing you know the idea that there's medical comorbidities that are not you know appropriate for the particular setting there's insurance issues there's all sorts of issues it just makes it really hard a lot of places don't want to bring in patients that maybe have disrupted behaviors or things like this which is by the way the precisely the point of going to psychiatric hospital to get this treated anyway this paper was published a couple years ago by a group in Australia who were trying to figure out how to count out beds that are available actually this is an interesting problem because if we don't know what our inventory is and we don't know what we need and so trying to trying to get an inventory count has been really challenging and so so you know the basic point is that evidence of bedlessness is out there we know that there's increased air placement of patients like hundreds of miles away we know that there's way longer boarding times we know that there's an increased rate of involuntary admissions and psychiatric facilities that do take patients that are and they're all 100 percent occupant have 100 percent occupancy rate most of the time decreased length of stay in these places increased acuity increases and discharges to homelessness or treating and treating and readmission we know all this is happening and this is all evidence that there's a bedless a bedlessness problem in the system we just don't know exactly what that you know what the the deficiency is or where it is and so this group was trying to figure out a way to count up beds and I'll show you some outcomes from their research in a few minutes but you know in the U.S. we have some of the we have the you know besides Chile Italy Turkey and Mexico the fewest inpatient psychiatric beds in among the OECD member countries so that's what this this list is it's you know we're at about 20 beds per 100 000 you know this is sub ideal on the other hand Japan is well outside the normal range and is problematic in the number of psych beds it has and I think it overuses those beds based on some of the research I've read out of Japan and actually a psych resident and postdoc who's now Hopkins is looking at this issue and trying to figure out why why Japanese society seems to really you know focus on inpatient psychiatric care as opposed to outpatient there's just too many too many people in psychiatric hospitals in Japan the reverse of our problem I think this is a kind of an infamous or famous graph that just kind of illustrates the the potential inverse correlation between deinstitutionalization and max incarceration and you can see the red dotted line is the number of psychiatric beds you know through you know the course of the 20th century it's really peaking in the 1950s and then dropping precipitously through the 60s and 70s and 80s down to like where we are now which is like 20 beds per 100 000 and then on the other hand you see this dotted line which is the number of individuals inside jails and prisons you know you know spiking and going up very rapidly in the 1970s likely due to lots of things related to the war on drugs and systemic racism and all sorts of factors that aren't really well the war on drugs is you know tangentially related to the mental health crisis but the idea here is that there are a number of factors that led to folks being mass incarcerated in mass and many individuals who had serious psychiatric conditions found themselves inside you know the criminal justice system in some way and still do today and I'll give you some numbers in a minute but the bed issue is this is like you know the classic understanding the common understanding of how the bed issue played out and now we're stuck with a very you know minuscule number of psychiatric beds compared to what we have now those beds weren't great let's be clear like it's not like we want to go back to the 50s and have all these asylums with you know people warehouse there was a capacity in the system is the point and you know there's this there's this theory by Lionel Penrose it's called it's kind of like a hydraulic theory when you decrease confinement in prisons you're going to see more people inside psychiatric facilities when you decrease hospital beds in psychiatric facilities you can see more people confined with mental illness in jail because there the idea is that there's a steady state population that will always need some kind of structured environment in some way and so like that's kind of curious it's controversial I don't know that I believe it myself but I think there is some intuitive logic to it and Richard Lamb who talked about in a second has some evidence that it's true these are just a couple of recent articles actually from the Seattle Times mental health project that illustrates exactly the problem that we're talking about today which is the problem of boarding the problem of rejection or declinations of care for individuals who are coming out of emergency departments and you can see these different facilities and why they're rejecting particular patients and you see medicals you know the main reason for a lot of these things administrative probably has to do with insurance and compatibilities behavioral issues again the idea that a person has disrupted behaviors or they're like a really you know quote unquote difficult patient that's that's part of it you know that to me is the fact that these facilities are rejecting people with with difficult behaviors is just another sign that there's a workforce issue at these places they just can't manage the patients that they're supposed to be managing right so that to me is like it's a workforce it's a major workforce issue we need more people in these places to help you know this is not an easy job and so you know you're often left with the the question of the person who has behavioral issues versus the person who doesn't and figuring out you know your staffing just can't accommodate the individual who maybe needs a one-on-one so that's a problem no beds of course and then just like random other reasons so let's get this slide this is this is a great report if anyone's interested in learning more about the issues related to beds bed counting the different the different diversions and ways people are discharged out of the the ed and where they where they often end up this is by the the treatment advocacy center from a few years ago in the national association of state mental health program directors they publish this paper i mean this white paper and you can see here you know 38% of psychiatric ed patients are admitted to the same hospital in in 2015 so that might mean again they go to a medical floor that's not exactly well suited for them there might be you know what they call what they used to call scatter beds throughout the facility that can be kind of shifted into mental health beds or re-licensed creatively into mental health beds and then another group of patients may end up in a community hospital or psychiatric or psychiatric scatter is actually psychiatric scatter beds are 5.1% you know so that's interesting they're staying inside the community hospital potentially or the the the the research hospital potentially on a floor that maybe isn't exactly as well suited for them or maybe they are on a floor that is a psychiatric floor but it isn't a long-term psychiatric floor it's more of a stabilization floor like and patients should shouldn't really be be there for more than a few months i mean i know that there's been patients and that pan at pennsylvania hospital where our inpatient wards are for over a year a couple years in fact in one case that's just not healthy or good or the outcomes just aren't good but there was nowhere else for these individuals to go so that's kind of another level of boarding it's like the boarding that happens in acute psychiatric wards when individuals need longer term care why is this happening another factor might be the fact that the federal government and you know instituted with medicare medicaid some rules one of the rules was that medicaid can't pay for bed can pay for healthcare for people in psychiatric facilities if those facilities have more than 16 psychiatric beds or mental health beds the intentions behind this rule were good they didn't want to see big warehouses opened again again you know this was passed back in the 1960s so that you know there's still really working through the the institutionalization process and everyone was starting you know was seeing these you know the footage the scandals of overcrowding and we you know the idea was to empty the places out and keep them you know shuttered and never to you know return again and one way to do that it was thought was to prevent you know the the collection of people in psychiatric facilities for you know for reimbursement purposes and they're just languishing there really and i get that so like that was that the argument was to keep things lowered and 16 beds if it's going to be a psychiatric facility of course you know the world's changed we have a different situation on our hands we have a mental health crisis at the moment and we know you know better how to treat people i think inside psychiatric hospitals and you know know that institutionalization is not good you know long term for most people that we have to figure out ways to re-enter folks into the community i mean i think we're a lot more sophisticated than we were in like the 1950s and 60s i think the IMD is an anachronistic policy that is actually really unethical because it singles out mentally ill people and says you know what we're going to limit the care that you can get in our policies we're going to limit our opportunities the opportunities for you to access care in no other field and no other medical specialty would the government you know say like oh well no you can't have more than five oncology beds it's crazy so you know to me it's it's and i gotta say i don't know that it's a big deal anymore there's so many waivers and so many workarounds that states can get that it's not clear to me that it even really matters that much anymore but to me it's it's the principle of it it's just the idea that this thing exists and says uh we're going to limit you know it's kind of like if we're you know in the middle of the pandemic and saying you know we're not going to hand out all our backs we're not going to give out all our backs we're just going to limit it or we're going to not produce as much as we need like we're intentionally limiting a resource that's already super scarce so and we have and and there's policies in place to de-incentivize or disincentivize the expansion of that scarce resource it makes no sense so that's my view um people disagree with me and that's fine but i think it's yeah so this is my um you know this is just like all the different states that have waivers and there's many other variations of these kinds of waivers you can do sort of in lieu care you know you can do care in lieu of reimbursement and get different workarounds and deals may pennsylvania has a whole arrangement that i can't even decipher uh with cms that allows for more beds in certain cases it's very complicated and that's part of the problem um this was just a piece that came out recently um by hannah furfaro who's a mental health journalist Seattle times i mentioned already they're doing great stuff on this basic you know you know the basic nuts and bolts issues of the problems of mental health care system in their mental health series so if you're looking for some good reading material i'd say take a look at their series on mental health um i mentioned that australian group so what they did was they um they wanted to figure out how many beds might be ideal for various settings and so they went to experts and created um a delphi panel and um and through that process and i was i was one of the panelists and we got lots of surveys and we had to work through lots of you know sort of vignettes and things and come up with different um recommendations through that process i think there were like 200 people in the delphi they kind of concatenated all of the opinions and came up with the basic idea that the optimal number of beds is around 61 per 100 000 um you know the minimum that is acceptable is about 30 you start to think about shortage between 15 and 25 and it's severely there's a severe shortage under 15 so we're kind of in that moderate shortage i would say you know based on these metrics treatment advocacy advocacy centers kind of you know sort of similar numbers a little bit more i think if i remember correctly it was closer to 75 per 100 000 whatever the case may be it's more than what we have we just need more and we should just be making more and i know that it's that's not all we need but it is something that we need so we need more beds um so fewer beds leads to homelessness leads to increased rate of suicide increased rate of violence burden on caregivers is something that we aren't talking enough about the need for parents you know to get respite care when it has seriously mentally ill children or kids with developmental disabilities the highest number of kids i think coming into the ED with mental health conditions also have uh you know also are neurodiverse so you know these caregivers parents you know we need to figure out ways to get them the support and the respite they need uh or else they're you know we're gonna have another you know a secondary crisis of of parents who need who need help and then of course incarceration is um is another result of incarceration of people mental illness is another i think consequence of having too few too few beds um when you look at the evidence you know you see in 1960 there were uh over a half a million individuals hospitalized for serious mental serious mental illness again not to say that was ideal or that you know even the concept of serious mental illness at the time is maybe different you probably included other you know non mental health conditions but nonetheless we had that capacity in in jails we you know as far as the records can shows 55 000 or so people with serious mental illness in 1960 that has completely flipped right now we have almost four i would say this is these data are very old these data are now seven years old so we have over 500 000 people inside jails and prisons uh with serious mental illness at schizophrenia bipolar disorder major depression many with personality disorders well over 50 with ppsd and then and then in in our hospitals our psychiatric hospitals we you know we have um relatively few um you know there's a six-time differential or so there between between the hospitals and the jails so um that just goes to show i think that individual serious mental illness maybe could have been in hospitals they're in jails you see this again this is the these are just some some numbers around different different mental health mental health conditions depressive disorder bipolar disorder schizophrenia all of these numbers are well above what we find in in the community prevalence numbers well above uh so this this that's what this graph shows you can see each of these is a mental health condition and the gray dots are the prevalence in the community the black dots are the prevalence in jails and each dot is actually a now that i remember this paper this is a meta analysis each of these dots is a a study that um that provided an estimate you can see the range for for example ptsd is really is really broad but but for other things it's very you know pretty clear that um that like schizophrenia is really really common inside jails compared to outside hints of two percent of communities upward to eight nine percent inside jails and these are exactly the people who you know should be in treatment millions right um that likely aren't dangerous either uh and and could really benefit from a treatment milieu uh supportive housing whatever it might be but certainly not jail and certainly not solitary confinement um which is where a lot of these folks end up the dynamic you know has been i think one of the criminalization of mental health conditions or mental illnesses you know where a behavior that's associated with a mental illness you know is becomes so significant and becomes sort of the proximate factor for their you know disruptive behavior the individuals involvement you know the individuals taken to jail first i mean there's now diversion programs all around and um you know samsa has a sequential diversion program there's various like co location um the programs for like 911 where police and social workers are trying to work together to deal with a crisis and get the person to the right place but you know those are still really new and the way things have been going is essentially like a person's disruptive they may be mentally ill they're taken to the city jail um where they often will languish because they're unable to make bail uh and they're not you know they're not capacitated uh and that's that's the idea of the criminalization of mental illness the trans institutionalization concept is the idea basically that there was this again this gradual shift in placement of individuals from you know hospital setting to say criminal justice setting and sort of like how these individuals migrate from one system to another depending on policies depending on uh science and the evidence and and other things um and you know richard lamb and linda weinberger have been arguing this for a long time um you know been very critical of the institutionalizations because they they argued that many of the persons that we see inside these jails with serious mental illness could have could have been in a psychiatric setting in a therapeutic setting had a bed been available and that's really true for a lot of people with uh who who committed minor crimes have serious mental illness and then when inside they decompensate they get worse they get violent whatever i mean it's a traumatic setting and then they're sort of stuck in that system um you know this is not a system that's designed for treatment this is like a group therapy session at um pelican bay state penitentiary out in california it's not exactly a welcoming group therapy milieu right um not to say these folks are safe who knows but you know the idea is that we're just not we're not going to get to seeing outcomes treating mental illness inside dungeons and jails as we will in in a well-designed psychiatric hospital um norris town state hospital here in pennsylvania this is like kind of an old slide but i just wanted to show like this is another issue like norris town state hospital is where we where we send jail inmates incarcerated individuals to get competency restoration if they're incompetent to stand trial and so they need to be treated and so they're they've been charged with a crime but they haven't been convicted of anything so they're innocent yet they're inside of the city jail waiting to get to norris town state hospital to stand to to go before a judge right and that process can take upwards to a year uh or you know or in five prisoners it's a 400 more than 400 days no crime no conviction living in jail serious mental illness waiting for competency restoration um me i'm gonna come back to that second um yeah so so this is a paper that i wrote a while back with um andrew seagull and zika manual in which we argued for a return to psychiatric asylum as a solution to the issue of individuals who are either being boarded but we don't talk i don't know if we talk about boarding here we talk about mass incarceration a lot and that's that was like my main animating um case uh for this paper and you know the idea was that we wanted to say you know we we should return to the notion of asylum not of the asylums but of asylum the original meaning of a protected place where safety sanctuary and long-term care for mentally ill people would be provided you know keying off of the concept as it was laid out by you know dorthia dicks and the quaker reformers of the 19th century um their ethos of a solutogenic environment where individuals can live and heal and have you know locational training and all the things that we think of now as you know new and you know whether it's horticulture therapy or or pet therapy or art therapy or no the quakers were doing this to a while a while back they were also putting people inside it in in penitentiaries which is bad too so it wasn't like they had all the answers but the idea was that moral treatment which was like the the revolutionary view of the time that mentally ill individuals are human beings that have dignity and that we should respect and that we can actually maybe heal like it wasn't like they were going to be like this forever if you put them in the right milieu with the right people with the right whatever maybe medicines i don't know um they might do better um and so that was revolutionary before it was like put them in bedlam right basically right and lock them away in a cage and and this is a much more hopeful view a progressive view of of of people um with mental illnesses of course you know the treatments were primitive and many were barbaric but the underlying i think ethics was um what was was was laudable um the history of the asylum goes really far back first asylum in europe was built in the in in like 1417 and in um uh where was that i'm trying to read the tiny print on my page here oh yeah the cathedral valencia spain fryer joffrey i forgot about fryer joffrey started the cathedral uh the first asylum in europe and then really the first psychiatric hospital in the united states was french hospital still open here in philadelphia runs basically on this notion again rooted in this idea of moral therapy you can still see i mean it's it's owned by universal healthcare so it's in more court it's a corporate hospital now it's a for-profit but you can go there you can see the old farmhouse the old grounds where the horticulture therapy took place the um animal husbandry stuff therapy you know the therapy that went on without us it you know it's it's all there uh we just need to think about you know creating spaces like this again and actually um i'm gonna skip this like because i think i'm sure it on time but i will say that you know the idea of the asylum brings up lots of makes people very anxious and nervous but um it doesn't have to i mean it could be it it could be a good place to be for people who who need a particular setting that's somewhat isolated and safe but not so isolated that you can't you know be with the community or family or whatever you know oliver sacks himself you know that the late great um neurologist and writer talked about how there is a virtue to the asylum and he went and visited to cooper rice and gould farm and he showed how the you know the positive elements of psychiatric inpatient care can be really enhanced um in these settings and you know cooper rice is like a farmstead type model where people go and it's kind of like framed as like a recovery college it's like a campus um it's not you know an inpatient setting that's locked right so people do have you know pretty serious mental illnesses but it's not like they're at the level where they have to be locked for safety um and you know they can access all kinds of resources there's um there's job training classes it's a pretty comprehensive program they have also this is down in ashville north carolina they also have like they have this sort of facility here out in the country and have one that's a little bit more in the suburbs like a house of course you know gundersen residents this is an asylum of sorts this is a place where people can go and uh i believe it's young women with borderline personalities uh can go you guys can tell me i forget now but um this is up there at mcclain right so uh another model of how to help people with this you know borderline personality disorder personality disorder in general in a residential facility with like wraparound services and intensive care gold farms same idea austin rigs same idea great places the problem is we don't have many of them and these places are all very expensive right and so you know at twenty five thirty thousand dollars a month i don't know what gundersen houses these days maybe it's like fifteen hundred dollars a day or something really people can't afford this right and so we need to scale we need lots of these places that are affordable to the world to the country to to general people to people who need these care these services like today right away we need to scale these places up we need to um have the government uh fund in conjunction with i think private you know payers somehow um really um well thought out but larger maybe not gigantic not like warehouse level but larger facilities larger campuses larger villages and therapeutic communities that can be sprinkled around every state so that people have access to the care they need when they need it uh let's see am i out of time lay i see it yes thank you that's a really um optimistic and good vision okay and i want to turn it over to benjamin to bring us into some brief q and a because i see there are a lot of questions yes uh thank you uh professor sissy for the amazing presentation thank you lia um and thank you uh again for everybody in the audience um your questions are amazing they're they're they're bountiful so we're only going to be able to to get to a few of them um between now and and and time um but um i'd like to to start us off with something that um i think will um raise a a good number of clinical and ethical issues and it's also kind of a case uh embedded in the question so i'll just start off with that um so the questioner says a pediatric hospital i used to work at rolled out a universal suicide um screening for all intakes and admissions but our urgent care department was excluded the rationale was that we didn't have the resources to address positive screens have you seen examples of or do you think this is an opportunity for offloading ed volumes as well as urgent care partnership without patient community resources um i'll turn it over to to whomever um wants to to go first but uh yeah i can comment a little bit on it um so i also worked at a pediatric hospital that had rolled out a very similar um model over the last year um i actually think it's a jaco mandate potentially um that is why that's happening but regardless um if i understand the question correctly um screening without being able to provide an intervention is really not useful um and so it's really important that if we're screening for something we're able to provide a useful intervention in that moment my impression from the question is that um at the in the urgent care setting um there isn't the ability to sort of intervene if necessary um and so one of the one of the potential ways to bridge that is is through an emergency room partnership or an emergency room back door if you will for patients who do screen positive they need further assessment and intervention although that could also further backlog the emergency room which is kind of what happened at the institution that i was at previously um don't the question don't ask or the the sort of notion don't ask the question if you're afraid of if you're if you're not prepared to deal with the answer um is both interesting and also potentially problematic because many individuals who go on to complete suicide have actually seen their primary care physician or been in touch with healthcare within the 30 days prior to completion and so it's sort of modeled after or or modeled after this idea that we need to ask the question to find the folks that are actually going on to complete suicide but many many places are not equipped to actually intervene and and it sounds like your hospitalism but one of many who don't have the resources for these positive screens and so i think folks are just trying to figure it out as they go but i think partnerships between acute care and urgent care and outpatient is is required to make a universal screening like that feasible in any way i might just chime in to say that um you know in thinking about this from the larger system perspective anything that decompresses the amount of patients going directly to the emergency department is a benefit so there would need to be this close collaboration between an urgent care center and an emergency department in case that patient does escalate up to need a more um safety contained environment or potential boarding and then placement into a bed but there are a large number of patients that are funneling through our emergency departments today that don't necessarily need that little level of structure you know as Jen as Dr. Gatz kind of outlined the most to least restrictive setting so i do feel like it would be a helpful step to maybe help divert a lot of those patients to that level of care amazing thank you um the next question um i think i'll we'll go to um uh Dom um just in light of the the the presentation and we can open it up to to Jen and Susan um if if if we have the time but um what do you think is the ideal relationship between um law enforcement and mental health facilities um and and systems and um not one uh no i don't i mean there's probably a important security you know function for certain patients of course but the way it is now it's way over security centric um and um you know it's just that interaction between criminal justice system and and our mental health care system is apparent when a person who has mental illness is taken from the jail to a hospital and and they're not you know and there's like a a prison guard standing by the door and they're still maybe even shackled inside a community hospital um so you know that the way in which mental health has been criminalized it you know it even follows the patient to a community hospital that notion right where they're not going to be treated like a patient still they're still treated like a like a criminal um so you know i think that's one aspect but then you back up and maybe as we've written about there's ways to avoid this entirely by diverting mentally ill people away from the criminal justice system and specialized diversion courts that seems promising but that again as we've talked about is just a drop in the bucket of a huge problem and it almost worries me you know this is the the way it had is that we're sort of giving you know we're sort of advocating our health care you know the health care system's advocating its duty to these patients to the criminal justice system and looking to judges to figure out what to do with their patients and that's just not right so um so i think you know whether we're talking about getting ahead of this situation at the back door by diverting people we're looking at how mentally ill people inside jails are treated you know and and and in community hospitals are treated um it's usually the case that the interaction isn't isn't a good one i mean and then you know crisis response is a whole other situation with 911 and 988 and how that all works you know i i would rather not see a police officer showing up to a mentally ill person's home in crisis um at first they may be they have to be in the background but if you could see a social worker uh clinical you know a nurse psycho you know a psychiatric nurse or somebody i don't know but any interactions between the police and mentally ill people police aren't trained for this they're getting CIT training crisis response training but they're not mental health care professionals and it's not fair to them to put them into that situation too um so that's a bunch of things about that thank you so much and and i'm i'm looking at the the the time and again i just want to i'll defer to lia i'm more than happy to keep on going there's there's such a long waste of questions and rich discussion going on both in the chat and the q and a but i want to be mindful of of the clock here i think we could go for one more wrap up question amazing um and i think this might be actually a a great one to think through um again just the the ethical and clinical um um dilemmas and perspectives that we we've had the chance to to to work through today so the question goes um are there any inpatient psychiatric hospitals where patients can stay while they taper their medications i guess i do we favor that um and are there hospitals where individuals suffering from psychosis can be treated without medications as is done in in norway for example or are us institutions still behind in this area i can comment a little bit on this and so i frequently spend most of my time tapering patients off of medications um not necessarily off completely everything but i do spend a fair amount of my time simplifying and refining medication regimens rather than adding new agents um one of the things that really challenging in the outpatient setting is um once a patient is even semi-stabilized or semi-doing a little bit better it's not always clear exactly what is responsible and they're still having some type of symptoms and and and physicians and providers are sort of scared to take anything away because they don't want to further destabilize somebody and should they add and add and add and that's a really common thing that i see the much of what i do is actually tapering folks off of medication um sometimes we do complete medication washouts in the inpatient setting it it's just safer to do in an inpatient hospitalization um it is only well i shouldn't say it is always but we always try to work with patients around whether or not medication is going to be a useful component to their treatments um medication is but one tool i would say that it by no means the only tool um nor even the most important tool um it is often a foundational component for many individuals who are struggling with various forms of severe and persistent mental illness um but but it is in no way sufficient to treat mental illness and i think that um that's where the other component becomes so vital um family and community support involvement helping the individual reclaim a sense of their identity and their purpose and their name helping to structure activity outside of the hospital so folks return to having a sense of self-efficacy um and really helping patients connect again with their sense of community these are vitally imperative pieces of the inpatient hospitalization and the transition out of the hospital um medication frequently helps patients be able to achieve some of those things but it is by no means curative um Dr Shilevsky or assist the any um a complementary thoughts um yeah so i maybe just supplement Dr Getz's answer by saying that as we think of inpatient right now as a very scarce resource we want to absolutely be thoughtful of the patients that need to be there so there are um a lot of medications that do not require inpatient level of care taper um and so those you know would be thoughtfully done more in the outpatient basis perhaps seeing their outpatient provider more routinely but there are certainly medications that we often prefer to do whether that's board loading the patient on these medications or taking them off in the inpatient setting just because of the potential side effects and medical complications associated with that hey i think that was the the unfortunately um probably the last question that we that we have available to us um so again just a really warm thanks to uh Dr Getz Dr Shilevsky Dr Sisti for amazing presentations and to all of you for the amazing conversation um and the amazing Q and A um so much to go through so much talk about we'd be here for the whole weekend um so just on this this note thank you again i'll pass it back to liya yeah thank you all all four of you so much for your engagement today and to everyone who is participating in the chat or listening and we will see you in october for our next session thank you all take care