127 Clinical judgments and professional behaviors are to a large extent shaped

127 clinical judgments and professional behaviors are

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127 Clinical judgments and professional behaviors are to a large extent shaped by attitudes. 128 Emergency department (ED) clinicians carry no special immunity to disparagement of persons with mental illness. The combination of mental illness and drug use disorders aggravates these attitudes and values. One motivation for these attitudes may be frequency of return visits. 129 Patients with mental ill- ness, psychological distress and/or alcohol and substance use disorders account for a high pro- portion of frequent ED attendees. In this regard, Washington State investigated the frequency of ED visits for persons with Medicaid. For EDs across the country, one-quarter of all ED visits are attributed to patients with Medicaid or State Children’s Health Insurance Program. 130 This 25 per- cent figure is second only to 40 percent for patients with private insurance; however, patients with Medicaid or State Children’s Health Insurance Program as their source of payment have substan- tially higher rates of return visits. 98 The Washington study found that ED visit frequency co-varied with mental illness and substance use disorders (Figure 2). For example, in the population of Medicaid patients that visited the ED 31 or more times within the span of 12 months, 56 percent had co-occurring mental illness and substance use disorder; 23 percent had only mental illness; and 10 percent had only substance use disorder. In this population, 9 out of 10 patients that visited the ED 31 or more times had mental illness, substance use disorder or both. 131 For the most part, individuals with high revisit rates have both mental illness and drug use disorders. Both together and apart, all of these patients tend to be seen as a nuisance and tend to worsen already compromised professional attitudes. Danger of physical harm is associated with EDs. Some portion of discrimination may be rooted in the genuine fears of the ED doctors and other clinicians. Police bring in violent patients routinely, and many big-city EDs have metal detectors to detect firearms and knives and other weapons car- ried by walk-in patients. Blurred lines and boundaries separate medical care, criminal responsibil- ity and violent patients with mental health problems. 132, 133 Psychiatry patients tend to be lumped into this basket of fears. Due to increasing patient volumes that never seem to let up, there is a constant sense of impending danger. In many ways these dangerous working conditions are among the forces that are bringing hospital-based EDs to the “breaking point.” 134
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Continuity of Care for Suicide Prevention and Research 30 Figure 2: Adapted and reproduced with permission; publicly available through Washington State. Mancuso D, Nordland D, Felver B. Washington State Dept. of Social Services and Health Services. 2004.
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