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Psychiatry Alone Cannot Solve Societal Problems

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On December 1 of last year, in keeping with his initiative to “clean up” New York City, Mayor Adams announced a directive for police and designated clinicians to exercise the involuntary removal of any person on the subway or streets who appears to have a mental illness to a hospital for psychiatric evaluation.

In the aftermath, we expect a substantial rise in ER patients with only 50 additional inpatient beds available to treat those requiring psychiatric admission. As resident physicians working in psychiatric ERs and on inpatient units, we are concerned. Without subsequent investment into all levels of our mental health system, this directive has the potential to weaponize our mental health care system against the city’s poor. 

Regardless of an individual’s route to the ER — via ambulance, police, or their own volition — psychiatrists assess for an underlying mental illness, changes in ability to function, and expected benefit of admission. We discharge those who can leave safely and find community-based care. In New York State, inpatient psychiatric treatment is attached to a legal qualifier under the Mental Hygiene Law: voluntary, involuntary, and emergency. Patients who warrant and agree to hospitalization can proceed with a voluntary admission. Involuntary commitment (including emergency) is a clinical decision held solely and judiciously by physicians. It is invoked primarily when patients are deemed to be “a danger to themselves or others” but also if they are unable to be treated in the community or are unable to care for themselves. If tasked to first-responders on the train, without the expertise of a psychiatrist, we predict a critical risk of bias toward our city’s unhoused and disproportionately to people of color: that by virtue of occupying the subway or street they are deemed incapable of self-care. 

As psychiatrists, we firmly support preserving patients’ rights to dignity and self-determination, regardless of the nature of the admission. Involuntary admission does not grant us the legal authority to force anyone to engage in treatment. Patients in New York who disagree with their commitment or proposed treatment may — and often do — refute these issues in front of a judge, with legal representation from the state’s Mental Hygiene Legal Service. We often see patients with acute mental illness promptly discharged, at times without medication, based on the determination of a judge. Simply admitting a patient involuntarily, therefore, does not ensure that the person is receiving meaningful psychiatric treatment. It can, however, further their distrust of the mental health system and prevent them from engaging in future care.

The purpose of admission is to provide patients in crisis with a protected environment where they can receive treatment for acutely decompensated psychiatric illness(es). While hospitalization is designed to restore a patient’s ability to safely live in society, it is not meant to be a long-term care option nor a holding cell for undomiciled people. Furthermore, inpatient care is meant to establish a therapeutic alliance between patient and treatment team. Forcing people who are not in crisis onto a locked unit to receive unwanted medications takes away limited beds from people who would benefit from this level of care and disproportionately imposes overly-restrictive treatment on those who are undomiciled.

Furthermore, mental health care is costly. Upon discharge, patients will be billed for inpatient services, whether or not they were hospitalized voluntarily. For patients admitted without insurance, the hospital Medicaid Office facilitates consenting patients through a New York Medicaid application to cover admissions and follow-up mental health care. To qualify, however, patients must have a physical address in New York State. Relatedly, discharging patients from a psychiatric unit requires them to have, at minimum, a home address and a follow-up psychiatric appointment within five days.

For unhoused individuals, the home address requirement frequently means discharge to shelters often against their wishes. At this point, it is important to consider why so many individuals are choosing to reside in public spaces rather than in our city’s shelters. Many of our patients rightfully feel unsafe in the shelter system due to incidents of muggings, physical attacks, and sexual assaults. When individuals are exposed to trauma within the very systems created to protect them, we need to re-evaluate those systems. Expecting our patients to return to housing situations that are unsafe and often dangerous is not only irresponsible, but also antithetical to the principle of nonmaleficence we commit to uphold as physicians. 

The second discharge criterion, follow-up psychiatric care, requires greater accessibility of community-based programs or state hospital facilities with the expertise and resources to care for this vulnerable population. Patients already wait months for a bed in state hospitals. Without support for such services many patients may be, frankly, “undischargable.” They are subject to prolonged hospitalizations due not to their mental illness, but to these discharge-related issues. 

If Mayor Adams’ administration wishes to provide quality and compassionate care for people with serious mental illness, there are several evidence-based interventions that clinicians, patients, and community leaders have supported with increasing urgency during the current mental health crisis. Proposed solutions include increasing access to community-based psychiatric care and step-down units after hospitalization, expanding insurance coverage for behavioral health, and training a larger clinical workforce. There are also several social interventions that are crucial to preventing, treating, and sustaining community wellness: affordable and supportive housing, meaningful employment opportunities, and robust social services to meet the basic needs of our city’s residents.

While we appreciate the increased attention toward mental health and the inequities in accessing care, psychiatry alone cannot solve societal problems. If we are to meaningfully help those with chronic mental illness living in poverty, policies must extend beyond the use of psychiatric emergency hospitalization and include extensive, long-term community support that respects patient dignity and autonomy. Involuntary interventions beg the question, “Will this help the human being in front of me?” Without wraparound services, involuntary removals will not be helpful, and therefore, are not ethical. We fear this approach disenfranchises the most vulnerable — namely the majority of our subway neighbors who are doing no harm. 

How do you feel about Mayor Adams's initiative? Share your opinions in the comments.

This article was written by Drs. Emily PhelpsRaia BlumEnzo Fantin-YustaJordyn FeingoldLillian JinHalley Kaye- KaudererMargot QuinnLaura van DyckShruti Mutalik, and Jacob Appel. The authors are psychiatrists in NYC.

Image by Kakigori Studio / Shutterstock

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