Inequality in Mental Health: Shown Through the Lens of Emergency Departments in the United States

Between 1992 and 2001, there were 53 million mental-health related emergency department contacts in the United States (Downey 2009). 23.6 out of 1,000 patients that come into the emergency department are due to mental health-related issues (Downey 2009). This is becoming a very prevalent problem in the United States, and it stems from several factors including inadequate alternatives consequently making emergency departments and their psychiatric emergency services a primary acute care setting, but also due to how we are socialized in the United States today.

I have been exposed to this issue in the Emergency Department at Oregon Health & Science University where I have been working for about six months now as a Research Assistant in the Clinical Research Investigative Studies Program. Over the past months, the part of the emergency department that has intrigued me the most is the difference in the treatment of “normal” patients who come in for “normal” clinical emergencies—motor vehicle crashes, chest pain, abdominal pain, etc.—versus patients that come in with mental health-related emergencies. There are many reasons that an individual can be classified as a psychiatric emergency including suicidal ideations (SI), violent or disruptive behavior, mania, intoxication states, and anxiety, among other presentations. Each of these chief complaints would be cause to place the individual in the psychiatric wing of the emergency department in the psychiatric rooms.

At the top of this post you can see two images depicting the differences between the psychiatric rooms at OHSU versus all of the other rooms in the department. As you can see there are huge differences, most notably that the psych room consists only of a bed on the floor in the corner of the room and has cameras in each corner to provide 24-hour surveillance of the patient in the room.

The question that comes to my mind each time I pass the psychiatric wing is: Is this subordinate treatment of mentally ill patients in terms of room type in the emergency department a form of inequality? Are these individuals being discriminated against due to their innate characteristics? In my opinion, the answer to each of these questions is yes. The treatment of individuals with mental health-related issues in a different type of room and wing of the emergency department compared to non-mentally ill related emergencies is comparable to other inequalities in society such as gender inequality and race inequality. Mentally ill patients are discriminated against due to their innate personal qualities leading to a new manifestation of inequality known as inequality in mental health. Inequality in mental health and illness is a longstanding issue in research that was initially studied by sociologists, but has now been taken up by many other scholars such as epidemiologists. In order to address the issue of inequality in mental health sociologically, we must look at the underlying issue as to how our society is socialized to perceive individuals with mental illness and consequently why they are treated differently once they arrive at the emergency room.

In modern research, there have been two contrasting theories as to why inequality in mental health exists. The first theory is known as social selection and it states that people become poor because they are mentally ill and thus unable to function in society (Ramon 2007). The second theory is known as social causation and states that individuals become mentally ill because of being poor (Ramon 2007). In each theory, however, we see the word social. This emphasizes the point that mental illness in it of itself and how society views mental illness is a social construction of reality in which we are socialized to view in a certain way. In modern society, we are socialized in such a way that creates a stigma that erodes confidence that mental disorders are real health conditions. We have allowed this stigma to grow an unwarranted sense of attitudinal, structural, and financial barriers to effective treatment and recovery, which has led to this problem of inequality in mental health that is emphasized by this example in emergency departments across the country.

 Mentally ill individuals do not have access to proper health care, medications, housing and other necessities that they cannot provide for themselves, which leads to another separate, but related issue in modern society. That is, mentally ill individuals make up more than 1/3 of the United States homeless population, or 250,000 people (Downey 2009). We can see the relationship between the two issues of homelessness and frequent emergency room department visits in that the deinstitutionalization, inadequate community resources, and the large number of uninsured homeless individuals causes the emergency room to act as a sort of primary care facility. Because emergency departments are acting as primary care facilities, the inequality in mental health is reinforced through the subordinate treatment of mentally ill individuals once they arrive to the emergency department—in terms of their room type as well as their actual medical treatment. The source of this disparate treatment is our social construction of reality that individuals with mental health-related issues are dangerous and outliers of society, therefore they must be kept in a special room, in a special wing of the emergency department. The ideas of fear and uncertainty toward mental illness have been ingrained in our minds through different agents of socialization, which has led to these evident disparities in treatment.

This problem could be avoided entirely however, if we, as the United States population and taxpayers of the country, were able to provide the support that these individuals need. Research has shown that if taxpayers in the United States were to provide the support in terms of housing, healthcare, etc., for individuals with mental illness, that taxpayers would actually save money each year. The frequent visits to the emergency room cost taxpayers more money and contribute to this inequality in mental health.  More importantly than saving taxpayers money, providing these necessities would help to end the inequality in mental health that we see across the United States in emergency departments, but also in many other situations, that stems from our socialization and apathy towards action to help.

References

Downey LV, Zun LS, Gonzales SJ. Utilization of emergency department by psychiatric patients. Primary Psychiatry 2009;16:60–4.

Ramon, Shulamit. Inequality In Mental Health: The Relevance of Current Research and Understanding To Potentially Effective Social Work Responses. Radical Psychology 2007.

Tartakovsky, M. (2012). What Many People Don’t Get About Mental Illness. Psych Central. Retrieved on December 1, 2014, from http://psychcentral.com/blog/archives/2012/11/04/what-many-people-dont-get-about-mental-illness/