Providing better medical care to those with serious mental illness will improve the health of the population of Washington State.

Any hospital in Washington State with an emergency department caring for surgical and medical emergencies should also be able to stabilize and provide inpatient services for those with emergent serious mental illness, such as psychosis, particularly for first episode or new onset psychosis. This is a psychiatric emergency, it is a medical illness, and there should be parity and parity includes treatment and hospitalization.  

How are hospitals allowed to discriminate against mental illness? This is not the case for most medical illnesses, if a patient is bleeding a surgeon is found, if an obstetric patient is in labor, an obstetric provider is found, why is this not the case with psychiatry?

Early, effective treatment of psychosis will improve both the short and the long-term outcomes for these patients. Just as protocols have been developed for the treatment of other serious medical conditions like stroke and diabetes, it should be unthinkable to leave a psychotic patient untreated and without medical care. These patients do not require a dedicated unit, they can be admitted to regular medical inpatient units for initial evaluation, for safety. Integration of mental illness care or parity in the acute short-term care would eliminate barriers and improve outcomes. Washington State can mandate that hospitals will lose their accreditation if they cannot admit and treat serious mental illness such as psychosis.

Untreated serious mental illness is medical negligence and this negligence is abetted and institutionalized by allowing hospitals to refuse to provide needed medical care. Eliminate the protection of the hospitals from accountability for this negligence. Require medical standards for the care of serious mental illness.

Allow the parents of single, unmarried, childless children to sue for wrongful death. The population most at risk for untreated mental illness is typically 18 or older and without damages having cost hospitals can neglect this population. And without early and effective treatment the outcomes of this medical disease are worse, the State and the public then pay the cost. Make medicine accountable for this medical disease, they are the responsible party, and without their help it is unsolvable.

For other medical illnesses particularly those with high mortality there are written medical standards of care with clear expectations for providers of this medical care. Establish a DOH task force focused on the medical care of those with serious mental illness and staff it with psychiatric experts. Require medical cases referred to the DOH MQAC or Medical Quality Assurance Committee for review to be reviewed by at least one psychiatrist. Recommend this new task force publish guidelines for the care of psychosis or other serious mental illness because standardizing this medical care will improve safety as it has done for other medical illnesses.

Those with psychosis have reduced to absent mental capacity, by definition a break with reality, and in fact often this disease results in a patient who does not know they are ill, refusal of treatment is common and a sign of the disease. A doctor can make this assessment and provide treatment based on medical need. But often hospitals use ancillary staff without the ability to deem mental capacity, so the patient must then be referred for a community designated mental health provider who may then take hours or even days to arrive.  This converts a medical disease into a legal matter, a competition between civil and criminal hospital bed access, decreased payments, less incentive to provide this care, and worst of all, it leaves the patient untreated.

Imagine hearing voices, hallucinating, suffering from psychosis and being neglected? A hospital would not leave an unconscious patient bleeding, or someone with a stroke untreated, they would provide treatment. What is the reason psychiatry and hospitals are allowed to escape this obligation to treat? Change the laws to protect those without mental capacity, save their lives, make treatment of their medical illness in the interest of the State. Make medicine do its job. Take away their excuse, “the patient refused”, force them to document mental capacity to refuse.

The hospitals, the doctors, the DOH, will all tell you they cannot do this work because they do not have enough psychiatric beds or psychiatrists to provide the medical care. Medical students do not choose psychiatry because there is low esteem and low pay for this career.  There is a shortage of psychiatrists and half do not bother with insurance billing. A patient with serious mental illness can be discharged from a hospital with only a list of providers to call many who will refuse their insurance or may have 2 month wait lists for an appointment. This is the same as sending someone home with no follow up care and this would be intolerable for other medical conditions.

But, these are all fixable problems, make medicine accountable, require them to admit and treat mental illness on parity as medical illness, change the compensation to reward psychiatry and hospitals for this care, locate outpatient psychiatric clinics on hospital facilities to increase fees, staffing, continuity, and timely patient access to these services. Build hospice like programs with home visits and medication refill services. Set up a program to pay back the education loans of those providing care for mental illness to help with provider recruitment.

Serious mental illness is a medical illness. It is an illness that often does not need expensive medical equipment or surgical centers, but it does need access to experts and most important, time with an expert, in a safe place, education of families, and wrap around and assisted outpatient services. There are models working around the world even up in British Columbia, nothing needs to be invented, the State needs only the will and leadership to provide change. Early and effective treatment of serious mental illness will improve the health and productivity of these loved ones.