Copyright ©2008 NPR. For personal, noncommercial use only. See Terms of Use. For other uses, prior permission required.

MICHEL MARTIN, host:

We're going to turn now to another problem plaguing some U.S. cities. Having to go to the emergency room can be traumatic in its own right. Having to wait for hours to be seen by a physician can be unbearable. But for those who suffer mental illness, the effect of lengthy wait times can be very serious. According to a recent study by the American College of Emergency Physicians, the wait time in emergency rooms is actually longer for those with mental health issues than for other patients.

Perhaps even more disturbing is the reason for the wait: fewer psychiatric professionals available to treat the mentally ill. For this week's Behind Closed Doors conversation, we talked to Dr. David Mendelson. He is the author of the American College of Emergency Physicians study, and Nancy Sharby, she is the mother of two young adults who both struggle with mental illness, and she's seen firsthand the effect of lengthy wait times. Welcome to you both and thank you so much for speaking with us.

Ms. NANCY SHARBY (Mother of Young Adults with Mental Illness): Thank you.

Dr. DAVID MENDELSON (Author, American College of Emergency Physicians Study): Thank you for having me.

MARTIN: Dr. Mendelson, what gave you the idea for this study?

Dr. MENDELSON: Well, we actually were tasked by our contingency, meaning most of the emergency divisions across the country that are part of the American College, to look into this on a national level.

It was a feeling across the country that we had long wait times and that an awful lot of the wait times came from boarding patients, which means once the decision to admit a patient to the hospital or send a patient to specific type of care, such as psychiatric care, has been made, because of lack of resources or no place to send them, they camp out and actually hang out for a long time in the emergency department, hours and hours and sometimes days.

MARTIN: Where does this system break down? Where are you starting to see the breakdown, and is it a breakdown for everybody, or is it a breakdown that happens to affect psychiatric patients, particularly acutely, for a particular reason?

Dr. MENDELSON: The breakdown happens at the point where the patient has been evaluated and been seen by the emergency physician. The emergency physician has made the determination that the patient needs further specialized care and needs to be evaluated by a psychiatrist. That's the point where things break down. We're waiting - we're trying to find the psychiatric resources, and that's where the hours and hours and sometimes days come in before these patients can get the definitive care that they need from psychiatric services.

MARTIN: And what's the effect of these waits? What are some of the things that happen as a result of these long wait times?

Dr. MENDELSON: There are multiple effects but there are two sides that we think about. For the psychiatric patient, it's terrible because number one, they're sitting in the emergency department, which is not a quiet, pleasant place. And if they have some kind of anxiety disorder, paranoid type of disorder, acute psychotic episode, a loud, busy, noisy emergency department with critically ill patients is not the best place in the world. So number one, it's not a great environment for them.

Number two, because some of our beds are being held up with these psychiatric patients, that's less beds available to move sick patients in from ambulances and from the waiting room and sort of the whole flow of the emergency department gets disrupted. So it gets affected on both sides.

MARTIN: Nancy, you have a son and a daughter who have struggled with bipolar disorder, as I understand it, but one of your kids, in particular, has - you've seen the effect of a long emergency room wait on him. Can you tell us about it?

Ms. SHARBY: For us, the first thing that happens is you go into the emergency room and they take you right back. They have to wait for someone to come down from the psych unit. That person evaluates him. They then have to call someone from other departments to evaluate him. They then call the insurance company, and then you wait to find a bed. So I would say the typical wait for us is 12 hours from admitting, walking in the ER, to getting a bed. But sometimes up to 24.

MARTIN: And what happens during those 12 hours? Can you just describe the effect on your son, in particular, of that wait? What tends to happen to him?

Ms. SHARBY: Well, my son is always quite agitated and manic, and he likes to walk around. Holding him in one place is very difficult. So putting him in a small, cordoned-off space not much bigger than a closet is extremely difficult. He gets more and more agitated. Sometimes it had to chemically restrain him, which means put a lot of drugs so he falls asleep.

One time, I remember, he was wearing only his boxers. He's a very large, muscular young man, and he decided to walk out of the ER wearing only his boxers, and there was nothing you could do to stop him. And three or four nurses and three or four security guards took him down. I watched it. It was awful.

MARTIN: It must have been hard for you as a mother to basically having six adults restrain your child.

Ms. SHARBY: And in the process of this, he bit someone. That caused great deal of difficulty for him. He then spent the next three days with a one-on-one security guard next to his door.

MARTIN: Does this happen a lot, Dr. Mendelson? I wanted to ask, if patients act out, does this then become a criminal justice situation, when it actually starts out as a medical situation?

Dr. MENDELSON: Unfortunately, yes. We end up dealing with patients like this who are psychotic, like you just heard, but can end up being dangerous to themselves or dangerous to the medical staff.

MARTIN: I am imagining that law enforcement officers don't want to deal with this any more than, you know, patients and their loved ones want to see it dealt with in this way. It just seems sort of obvious that everybody has an interest in addressing this. Dr. Mendelson, do you have any idea of way it hasn't been? Why is this situation allowed to persist when I bet you anybody who has worked in an emergency room has seen this go on and on and on?

Dr. MENDELSON: Well, I think that in general, across the country, it has been allowed to persist just because it wasn't clear what the answers were and certainly the funding for getting to those answers, you know, has been cut more and more over the years. There are pockets of places, and I say pockets because it's very small around the country where this is handled properly, but it's very, very rare, and we need to get that more spread out and more available throughout the country.

MARTIN: But doctor, if you could just clarify something for me. You're talking about a history of funding cuts. Funding cuts in what areas? Are you saying just a shortage of hospital beds, in general, which leads to longer wait times for everybody? Or are you saying that specific funding cuts for psychiatric services?

Dr. MENDELSON: Well, both. In years gone by, there was enough excess capacity in the emergency departments throughout the country where this issue didn't sort of rise to the surface like it is or became quite so visible. There is no capacity like that anymore, and probably some of the most at-risk patients are psychiatric patients or acutely psychotic patients, and that's why we're hearing so much about it now.

MARTIN: Nancy Sharby, Dr. Mendelson was describing situations that have been handled well and handled poorly. You just told us about a situation where your son became agitated, had to be restrained. That was obviously very traumatic for everybody. Have you ever had a situation that was handled well? And what's the contrast?

Ms. SHARBY: Partly, it's having staff who are sensitive to the situation. We've been to one particular emergency room many times. I can now call them in advance. I could say my son is coming. They'll go upstairs. They'll get his records. They'll bring it down to the ER and actually be waiting for him, and that's wonderful because they know how to handle him. They know what he needs, and they can handle it expeditiously, especially with the insurance company.

When it's bad, is when - there was one time when we had the only psychiatric bed in the entire city of Boston was the hospital where my son was in the ER, and the insurance company wouldn't let us have it because they weren't in our network of care. And the ER doc and I fought for about six or eight hours till they finally let us have the bed.

MARTIN: And what was he doing during all of this?

Ms. SHARBY: He was in the quiet room with the security guard outside the door, pacing.

MARTIN: Pacing. What is going on for him? Has he ever been able to describe for you what is going on for him at times like that? What feels like?

Ms. SHARBY: No, he doesn't really recall it afterwards but he does describe how he just wants to be not there. One time at emergency room when his girlfriend came in, and the two of them actually laid down on the floor together, and that was extremely calming for him. But that's a really rare occurrence, as well.

MARTIN: Dr. Mendelson, do you see - were these findings a surprise to anyone? And do you see any response by policy makers to these findings?

Dr. MENDELSON: They really were not a surprise to us, and I was pleased once we got the survey results that what we saw had come back - in fact, it was a little worse than I thought it might have been before we did the survey. The nice part about it is we were able to share this with American Medical Association, and they have basically latched onto this issue and I think that you'll hear a lot about this, and especially after the elections, in the upcoming next six months to a year.

MARTIN: Really? Why do you think that?

Dr. MENDELSON: So many of the constituents of our legislatures have heard about this issue because it's such a big issue for the hospitals and to all patients who come to the emergency departments, and certainly a huge issue for psychiatric patients.

MARTIN: Nancy Sharby, can I ask you, how are your kids doing now, particularly your son?

Ms. SHARBY: Oh, very well. He's planning to go to college in September. His last hospitalization was about a year and a half ago, and things are going quite well.

MARTIN: What's made the difference?

Ms. SHARBY: We found the right medication for him. We found the right treatment team for him, and that makes all the difference in the world.

MARTIN: And your daughter, I don't want to leave her out. How's she doing?

Ms. SHARBY: Oh, she's doing very well. She's getting married in November, and she's a very happy woman.

MARTIN: Oh, wow! Best wishes to you both.

Ms. SHARBY: Thank you.

MARTIN: Nancy Sharby is the mother of two mentally ill children who are doing well, as you just heard. She joined us from WBUR in Boston. Dr. David Mendelson is author of the American College of Emergency Physicians study on emergency room waits for the mentally ill. He joined us from Austin, Texas. I thank you both so much for speaking with us.

Ms. SHARBY: Thank you for having me.

Dr. MENDELSON: Thank you for having me.

MARTIN: And now, we'd like to hear from you. Have you or a loved one experienced a long waiting time in the emergency room, particularly when you were struggling with a mental illness? What effect did it have on you? What solutions have you found in your experience? What made a difference? Please go to our Web site and share your story. Just go to the Tell Me More page of npr.org, or call us at 202-842-3522. That's 202-842-3522.

Copyright © 2008 NPR. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to NPR. This transcript is provided for personal, noncommercial use only, pursuant to our Terms of Use. Any other use requires NPR's prior permission. Visit our permissions page for further information.

NPR transcripts are created on a rush deadline by a contractor for NPR, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of NPR's programming is the audio.