America's ER's: Prisons for Victims?

Everyday on my psychiatry rotation, I see a disproportionate number of young African-American males, who have been involuntarily committed to the Duke University Hospital Emergency Department for wanting to kill themselves or others. They are locked together in a holding area for days to weeks at a time, and receive intramuscular injections of anti-psychotics to restrain them. Many of my patients do not have fathers, homes or anyone who truly loves them. They are victims of violence and unfair childhoods. Their wounds are not rooted in biological phenomena, but rather in social injustice, and they deserve more comprehensive care. They deserve to be in a place that is healing, to be empowered and not restrained.

I am told it is similar at the more than 5,000 emergency departments across the United Sates. Seeing this treatment exists is shocking to me, and I seek to give them a voice. You have the power to prevent this, to tell your legislators, to tell the American Medical Association that the mental well being of the urban underserved matters. As a second year Duke medical student, I seek to share my experience with you.

I feel fortunate to walk through large, modern, glass doors each morning, past the 2012 Nobel Prize, into a cathedral of stimulating, novel discourse found only at one of our nation's top medical schools. As I arrived at my psychiatry lecture, I was quickly sheltered by my intellect, like a towel being thrown on Duke basketball stars as they return to the home team bench.

The psychotic patient is described as interesting, the personality disorders are peculiar, the mixed episode is novel. The patient experience feels uncloaked, filtered neatly, like pasta being strained. Does this meet APA Diagnostic Systems Manual criteria or not, did the psychosis last for six months, are we missing a positive symptom to finalize the diagnoses? Patient found in room with computer cable around his neck: Does that count as a suicide attempt? How serious was he about dying? We are molded into professional behavior and emotion analyzers, responders and human data mines. And our toolkit is growing. We can fix behavior and emotion quite well. We do discuss the traumatic etiology underlying many diagnoses, but the traumas are nameless, "one might have faced trauma in his youth, one could have been ignored by their parents". Our humanistic clerkship director has noted that earlier family intervention might prevent some of these conditions. I seek to personally try as a primary care physician. But tomorrow, I'm back in the PEU.

The PEU is a part of the emergency department known as the Psychiatric Emergency Observation Unit. It is a double-locked holding area, with eight beds. Kind of like entering an air-tight clean room, you swipe your badge to enter the nurses' observation deck, and then swipe again to enter the Unit.

The PEU is an open space with single walls separating beds -- housing both males and females. If you were to come to the emergency department in handcuffs, threaten to kill someone or kill yourself, I would see you tomorrow. If you come to the emergency department with a different issue, and are recalcitrant towards a staff member, that is also grounds for a transfer to the PEU. As a requirement for being in the PEU, you are asked to change into disposable paper scrubs, and disposable underwear. You will not leave the PEU for several days, and often weeks until you are either stable, or there is an available bed for you a nearby psychiatric treatment facility. There simply are not enough treatment beds. If you would like to use the restroom, there is a single toilet you may use. If you challenge authority in the PEU, you will receive an injection of Haldol, an anti-psychotic mediation to make you calm enough that you will no longer challenge authority.

There were multiple points during the past two weeks, when everyone in the PEU was black. According to the U.S. Census Bureau, 38.6% of Durham County, North Carolina identifies as African-American or Black. Every second year medical student at Duke knows this statistic, from our course last fall on prevention and health disparities. My mere observation of PEU ethnic diversity may be an anomaly, however I feel my two weeks in the PEU has provided enough data points to at-least ask the question: Why does it seem there is a disproportionate number of Black adolescents in my community facing psychiatric emergencies? And facing the current dehumanizing treatment that couples such emergencies?

"The new patient in the PEU wants to hurt someone and kill himself," I heard from a staff member. My first response was fearful, and inquisitive. Why would someone want to do that? He must have a mental illness, a biological disorder I reasoned from my recent training.

He had one dollar; I noticed in the list of belongings posted to his chart. Interviewing him, I discovered an African-American teenager, without a father, without a home, seemingly without anyone who really loved him. A victim of violence, an unfair childhood, an under-performing education system. And he also wanted to hurt someone and kill himself. No, not also, not on a separate line of my history of the present illness. The etiology suddenly seemed pretty clear to me. He was reasonably angry and sad, had gotten pushed down, and gotten back up, too many times.

Let's forget the fancy criteria and terminology in my DSM diagnostic manual for a few minutes. Is the core fact that deserves most of my attention, the notion that he has Major Depressive Disorder? Was remembering this, really what was going to allow us to fix the problem? He had received that diagnosis several times before in the PEU, and he was back again. His life is a million times harder than mine -- a million times less just. I didn't feel right diagnosing him, and recommending a medication regiment to my attending physician, bestowing my clinical judgment upon him.

Is the answer isolation, a diagnosis and a shot of an anti-psychotic medication to calm individuals in his circumstances down? Had he ever been hugged unconditionally before? He clearly needed to be embraced, to be loved, to have access to quality mentors in his community, and preventative mental health services for times of crisis.

He will be discharged some day soon, fixed of his disorder, his feelings medicated away, temporarily. The emergency department psychiatrists will have done their job, and quite well. I'm not forging an affront of emergency psychiatric treatment, rather distilling that we must not pretend psycho-pharmacology is potent to yield a cure. We cannot pretend this model of diagnose and treat is valid to repair unjust experiential wounds, a lack of developmental nurture. And foremost, we must remember, these wounds are not rooted in biological phenomena.

I end in solidarity. I have a problem with this picture. I am tired of being a bandaid on a problem, pretending to identify and fix biological error with DSM-V criteria. I think we make a mistake by labeling people with names of mental illnesses who really are victims. The real disorder is with us, with our society. We allow people to become victims. By being bi-standers to injustice, we yield much psychopathology. As the world's leading economic power, we have the largest homeless population in the developed world, the highest incarceration rate in the entire world and we spend more on prisons than we do on shelter or schools. And the racial inequalities are undeniable.

To the physician readers, as a humanities major, I call your attention to our vernacular. Linguistics connote significant meaning. I propose that we no longer diagnose victims of social injustice with psychiatric illness. Rather, I suggest we remind ourselves, we de-intellectualize ourselves and qualify the individual's experience. Our assessment and plan should yield depictions such as, "This patient is an African-American male whose unjust educational background, unjust social experience in East Durham, meet criteria for Major Depressive Disorder." It's time we stop bestowing clinical judgment upon victims, and start taking responsibility for our society.