A new statewide study gives an objective and detailed review of Virginia’s emergency mental health system, sheds light on persistent gaps in available services and illustrates the need for timely access to mental health services, including access to crisis response services and psychiatric beds.
The report, “A Study of Face-to-Face Emergency Evaluations Conducted by Community Services Boards in April 2013,” was led by University of Virginia law and medicine professor Richard Bonnie, a leading expert in public policies related to mental health. The principal investigator was Elizabeth McGarvey, associate professor of public health sciences at U.Va.
As part of the study, the researchers asked clinicians in Virginia’s 40 locally run community services boards – which serve as the intake system for public emergency mental health services – to collect detailed data for each of the 4,502 emergency evaluations conducted in April.
The analyses of adult evaluations in the report excluded people who were already under commitment orders or were in jail, leaving 3,436 adult evaluations for thorough analysis. Approximately 600 of the individuals evaluated were juveniles.
The study aims to provide policymakers and stakeholder organizations with concrete information on:
- The rates of involuntary and voluntary hospitalization,
- Access to services and resources that could avoid the need for hospitalization,
- The amount of time spent searching for psychiatric beds, and
- The adequacy of time limits on emergency custody orders.
“A central aim of our mental health services system is to assure that people experiencing a mental health crisis get the help they need, when they need it, before things spiral out of control,” said Bonnie, who is also director of U.Va.’s Institute of Law, Psychiatry and Public Policy and a professor of public policy in U.Va.’s Frank Batten School of Leadership and Public Policy. “The goal of this study is to ascertain how effectively this mission is being carried out in the various regions of the commonwealth.”
A key finding of the study is that clinicians reported that involuntary hospitalization could have been avoided in more than a quarter of cases if alternative services or resources had been available. Just under half of the voluntary hospitalizations could have been avoided.
“Some regions still lack programs that can provide residential care to help stabilize the person’s psychiatric condition without the intensity and cost of hospitalization,” Bonnie said. “Even though providing statewide access to sufficient crisis response services has been a policy priority for more than a decade, more needs to be done.”
A shortage of psychiatrists, particularly in rural parts of the state, was also frequently cited.
“About one-tenth of the involuntary hospitalizations and one-fifth of the voluntary ones could have been avoided if an immediate psychiatric evaluation had been available,” Bonnie said.
According to the report, one out of every two people evaluated presented an elevated risk of serious harm toward self, and one out of every three were found to have an impaired capacity for self-protection or an inability to provide for their basic needs.
One out of five adults was found to have an elevated risk of serious physical harm toward others.
Involuntary treatment was recommended in 1,370 cases, or 40.2 percent, of the 3,436 adult emergency evaluations. Voluntary hospitalizations occurred in 17.7 percent, or 603 cases.
A supplemental report found significant differences in rates of hospitalization, both voluntary and involuntary, across regions of the state. For example, the hospitalization rate ranged from a high of 69.2 percent in Region 4 – which includes Richmond and surrounding counties – to a low of 41.7 percent in Region 6, which includes Danville and portions of Southside. Statewide, the average rate for hospitalization was 57.9 percent.
In the cases where the emergency services clinician concluded that the person needed to be hospitalized, the next task was to identify a hospital willing to admit the person under a temporary detention order. The study casts light on the length of time needed to find a hospital bed. In the vast majority of cases of involuntary hospitalization, a psychiatric bed was located within four hours or less. In 8.4 percent of cases, finding a bed took between four and six hours. And in 3.4 percent of cases, it took more than six hours.
The length of time needed to identify a bed is particularly important in cases where the person is being evaluated involuntarily, Bonnie said. When an emergency custody order is issued, a clinician has a four-hour window, which may be extended by two hours, to contact mental health facilities to find a psychiatric bed. After the maximum six-hour window expires, the individual is legally free to leave.
“In a limited number of situations, six hours is not long enough to find a suitable bed,” Bonnie said. “It’s about 3 percent of the roughly 1,400 adult temporary detention order cases a month – but of course you want it to be zero.” A bed was eventually found for almost all of these individuals even though the order had expired, he added.
For cases in which the person was hospitalized, the majority of the facilities were located in the same region as the person’s residence. In 259 cases, or 14.8 percent, however, the admitting hospital was in a different region. The study also revealed sizable regional variations among the availability of psychiatric beds and how many calls it took clinicians before they found one.
“From a statewide standpoint, a lack of psychiatric beds is not a huge problem in Virginia,” Bonnie said. “But, unfortunately, it is a problem in some localities. In some cases, you have to send patients out of their region, which makes it harder for them and their families, and it sometimes takes longer than it should to find a bed.”
The study was commissioned in the summer of 2012 by the Virginia Department of Behavioral Health and Developmental Services.