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We are the hollow men: The worldwide epidemic of mental illness, psychiatric and behavioral emergencies, and its impact on patients and providers

2017; Medknow; Volume: 10; Issue: 1 Linguagem: Inglês

10.4103/0974-2700.199517

0974-519X

Veronica Tucci, Nidal Moukaddam,

Child and Adolescent Psychosocial and Emotional Development

Those who have crossed With direct eyes, to death's other Kingdom Remember us-if at all-not as lost Violent souls, but only As the hollow men The stuffed men This is the way the world ends This is the way the world ends Not with a bang but a whimper. –T.S. Eliot, The Hollow Men All across the world, patients are coming to their local Accident and Emergency Departments/Casualty Centers (EDs). They are in pain. Sometimes, their eyes scream out their suffering and other times they appear as cold, empty shells reflecting the hollowness the patient feels inside. Unlike patients with compound fractures or lacerations, patients with psychiatric illness have wounds that are rarely visible to the naked eye. This is the way the world ends, not with a bang but a whimper. This is the face of mental illness, the stark picture seen by emergency physicians and psychiatrists, with problems ranging from depression to suicide and psychosis, as well as addictive disorders. An estimated 350 million people worldwide suffer from depression. The World Health Organization has predicted that by 2020, depression will be the second-leading cause of disease burden globally.[1] Depression is set to outpace ischemic heart disease as the number one cause of disease burden worldwide by 2030.[2] The Centers for Disease Control and Prevention has estimated that depression impacts more than 26% of the US adult population with more than 1 in 20 reporting moderate to severe symptoms and that 25% of adults in the United States will suffer from mental illness this year and nearly 50% of adults will develop at least one mental illness during their lifetime.[3] Indeed, in the United States, from 1999 through 2014, the age-adjusted suicide rate increased 24%, from 10.5 to 13.0/100,000 population, with the pace of increase greater after 2006.[4] Similarly, after noting a downward trend from 1981 to 2004 (15.6–10.4/100,000), the United Kingdom has seen a rise in suicide since 2007 to a level of 11.9 in 2013.[5] However, suicide is not just a “ first world” problem. According to suicide.org, the global suicide rate is 16/100,000 and global rates have increased over 60% in the last 45 years.[6] One person commits suicide every 40 s. The highest rates of suicide are in the former Soviet bloc with Lithuania reporting the highest rate worldwide of 70.1/100,000 population.[6] The national institute of statistics for Mexico also reports an increase in the number of suicides from 2000 to 2013 with a current rate of 5/100,000 population and choking, suffocation and strangulation is the preferred means to complete suicide.[7] Unipolar depression is not the only psychiatric condition reaching epidemic proportion. Currently, an estimated 60 million people globally suffer from bipolar depression and an estimated 21 million people suffer from schizophrenia.[8] Rates for psychosis also appear to be rising. The Department of Health Policy Research in the UK saw an annual incidence in 2012 of 32 cases of schizophrenia per 100,000 people and 21 cases of affective psychosis.[9] The statistics are frightening. Many state hospitals are now closed, and community outreach programs are stretched to the breaking point. Chronically underfunded and perpetually overwhelmed, outpatient centers are simply unable to cater to the demand for their services. The mentally ill, caught in the middle, are left with no recourse but to turn to their local ED. Indeed, between 1992 and 2001, there were 53 million mental health-related ED visits in the United States. In 2006, 4.7 million patients flocked to American EDs with a primary psychiatric diagnosis, a rate of 20 visits per 100 adults.[10] By 2007, psychiatric and behavioral emergency visits doubled and mental health is the one area of Emergency Medicine practice that continues to rise with no end in sight. Moreover, Emergency providers need to be on guard even when patients present with what appear to be purely medical complaints. An alarming 8% of ED patients with medical issues admit to being actively suicidal when asked (Claassen CA, Larkin GL. Occult Suicidality in an Emergency Department Population. The British Journal of Psychiatry: the Journal of Mental Science 2005; 186: 352-3). The economic costs of mental health are exceedingly difficult to pinpoint. One group, The Agency for Healthcare Research and Quality, estimated that mental health care costs for the United States in 2006 were approximately $57.5 billion dollars.[11] Another study estimated the cost or economic burden of just unipolar depression and related conditions (e.g., dysthymia/persistent depressive disorder) in the United States to be $83.1 billion in 2000.[12] The incremental economic burden of individuals with MDD was $173.2 billion in 2005 and $210.5 billion in 2010, an increase of 21.5% over this period. A large portion of this increase was attributed to higher direct medical and workplace losses. This great variation in noted costs likely depends on whether the author is referring to direct costs (e.g., payment for clinic visits, hospitalization for medical treatment for suicide attempts) and/or indirect costs (e.g., workplace losses). Similarly, in 2011, the World Economic Forum delivered a chilling forecast and estimated the cost of mental health conditions worldwide in 2010 to be $2.5 trillion dollars, with the cost projected to surge to $6 trillion by 2030.[13] Regardless of which benchmarks experts use to calculate mental health costs, all studies have shown a significant rise in the cost of mental health over the past decade, and that is a trend likely to continue both in the United States and abroad. However, the economic burden of mental illness does not paint a complete picture of the toll of mental illness on the patients or the care providers challenges associated with psychiatric patients. Emergency physicians and intensivists had the highest rates of burnout as demonstrated by a loss of enthusiasm for work, cynicism and a low sense of accomplishment.[14] Indeed, one study in Romania, using the Maslach Burnout Inventory, unsurprisingly showed Emergency physicians experiencing a high level of emotional exhaustion and even scored lower on personal achievement than their emergency nursing colleagues (this was partially attributed to less sleep and longer shifts).[15] In their introduction, the authors cited “GOMERs” as an important source of stress for Romanian doctors and are the main cause for ED crowding. “GOMER,” short for “Get out of My Emergency Room” was used by Popa et al. to refer to geriatric patients with multiple neurological and psychiatric conditions. The authors go on to state that the mere presence of such patients is an attractor for negative countertransference from staff and other patients. Additional research is needed to delineate the effect different patient subgroups including those who are experiencing behavioral or psychiatric emergencies have on the burnout of emergency providers. In this issue of International Journal of Academic Medicine, readers will find cutting edge reviews on several key areas in the management of acute exacerbations of mental illness including identifying depression and suicidality, assessing stability in emergency psychiatric patients, managing patients with addiction and withdrawal, recognizing the causative factors for altered mental status, and issues that affect children and adolescents as well as medicolegal factors that impact the delivery of emergency psychiatric services. The articles are written from an interdisciplinary perspective, highlighting the dire need of collaboration between psychiatry and emergency medicine, and the great strides we can accomplish if we work together.