There is a glimmer of hope for those suffering from serious mental illness. On July 6, the House of Representatives almost unanimously passed the Helping Families in Mental Health Crisis Act. Although lacking significant new funding, the bill introduces reforms that seek to expand access to acute psychiatric care while also bolstering community-based programs, such as assisted outpatient treatment, that have a proven track-record of reducing hospitalization and incarceration. It remains to be seen when the Senate will act on this legislation.

I can only hope it will be soon, because I’ve seen firsthand how desperately we need it. As a psychiatry resident training in San Francisco, I’ve spent countless hours providing care in local public and private hospitals, medical emergency departments, and the city’s psychiatric evaluation service (PES).

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These experiences have taught me a couple of things. First, a psychiatric emergency involves foremost a great deal of suffering: while the hopelessness of the suicidal patient may be plain to see, overwhelming fear and despair likewise often underlie behavior that, to the casual observer, may appear bizarre or frightening. Second, emergency departments are not designed to deliver the humane care that such mental suffering necessitates. That requires a safe environment, adequate staffing, social services, and encounters with trained therapists.

Too often, instead of promptly admitting a patient in crisis to a hospital ward built to provide this sort of care, I deliver him the news that that he will be spending the next several days in a windowless emergency room. Eventually he may indeed be admitted, though in many cases he will simply be discharged after achieving some minimum level of stability. Either way, his belief that there is such a thing as a mental health safety net will no doubt have been damaged. He will learn that, in a moment of crisis, a call for help may result in little more than several days in purgatory.

At San Francisco General Hospital’s PES, stays exceeding 100 hours (and in some cases much longer) have become common. Whereas PES employs trained psychiatric staff, during the roughly fifty percent of the time the service is full, patients are diverted to other emergency departments that, despite devoted and highly professional staff, typically lack the basic resources needed for good mental health care. Likewise, on general hospital wards, those needing psychiatric admission often wait for days after their medical problems have resolved. I cannot count how many times I have, in a consultant’s role, apologized to perplexed internists and surgeons who, like me, see the obvious injustice of leaving someone in crisis to linger in a hospital room, largely alone, without the therapeutic services provided in our psychiatric unit. 

This situation has arisen in no small part because of staggering cuts to mental health services over the last several decades. These cuts are only part of problem; addiction, economic and racial injustice, and the gutting of various social programs play major roles as well. But within the mental health system specifically, the declines are well documented.

California lost 32 percent of its acute psychiatric beds between 1995 and 2011. Nationwide, the US has only 11.7 state psychiatric beds per 100,000 people, compared to 14 in 1850. In the name of revenue, private psychiatric units have been downsized or left out of new hospitals altogether.

Instead of receiving care in dedicated facilities, the severely mentally ill are increasingly winding up incarcerated (several of the nation’s largest mental health providers are, in fact, county jail systems). Community mental health care, once promised as an answer to institutionalization, has suffered cutbacks: In the last few months alone, Connecticut announced millions in cuts to its mental health department, while Oklahoma imposed new barriers on Medicaid patients seeking psychiatric care.

A functioning mental health system needs to feature a spectrum of services to help individuals go from crisis to stability to recovery. Critical components include hospitals, emergency services, mobile crisis teams, supportive housing programs, and comprehensive community-based care. When I meet patients in crisis, many have encountered multiple failures at all of these levels. All too often, I am unable to break that cycle. Rep. Tim Murphy’s bill is merely a first step. It is in many ways a modest one, and by no means perfect. But, shortcomings aside, for the first time in recent memory the federal government is poised to acknowledge what many of us working in psychiatry already know: our system is broken, and it needs fixing.


Jacob Izenberg, MD is a psychiatry resident in San Francisco and a member of the Committee of Interns and Residents