Alleviate Psychiatric Boarding in Washington with Telepsychiatry

Pierce County Superior Court Judge Kathryn Nelson granted a second six-month stay on a June ruling regarding the unlawfulness of “psychiatric boarding” on Dec. 10, 2013.

The delay marks the state struggling to solve a complex problem that, at its crux, is about a shortage of psychiatric and behavioral health care. I challenge Washington to consider innovative solutions like telemedicine to alleviate some of the problems associated with psychiatric boarding.

Psychiatric boarding is when a mentally ill resident is detained, often in a hospital emergency department, while waiting for proper psychiatric treatment.

There is a laundry list of negative effects from psychiatric boarding. Mentally ill patients are not receiving the care they need, and many of them are being involuntarily detained until a psychiatric provider is available. This can lead to frustrated patients who are at an increased risk for harming themselves or others as they wait.

According to an October article in The Seattle Times 4,317 psychiatric patients were boarded in Washington in 2012. [1] A national study of 300 Emergency Department directors found that 41% of patients wait 2 days or more for psychiatric care. [2]

Secondly, because Emergency Departments are crowded with psychiatric patients waiting for care, patients with other medical concerns face long wait-times and similar treatment delays.

Lastly, psychiatric boarding is a significant drain on hospital and community resources as staff, and often police officers, are needed to observe detained patients.

Why is this happening?
There has been a decrease in the number of psychiatric beds. In Washington, the number has dropped from 1,759 beds to 1,507 in just five years. [3]

Additionally, there is a shortage of psychiatrists in Washington. U.S. News reports 811 Washington-based psychiatrists, which equates to 1 psychiatrist for every 8,504 people.[4] National trends reflect a similar shortage. One study found 96% of counties within the US have unmet needs for psychiatric prescribers.[5] I propose a solution that could alleviate some of these needs by increasing access to providers: telepsychiatry.

Telepsychiatry is psychiatric care provided via videoconferencing. It is a proven medium of care and a way to increase access to Washington-licensed providers who may live in other parts of the country. It is also a way to better leverage the time of existing Washington-based psychiatric prescribers who could seamlessly transition between appointments at different hospitals without having to physically travel, as many of them now do.

Telepsychiatry providers could be used in several ways:
1) In hospital emergency departments: By incorporating 24-hour on-demand telepsychiatry programs, hospitals could have timely access to psychiatric providers for commitment and treatment decisions. Experienced psychiatric nurse practitioners and psychiatrists consistently assess risk with a high degree of certainty and therefore can significantly reduce unnecessary admissions, which frees up beds for those who need them and sends home those who don’t.

2) In inpatient units or psychiatric hospitals: Washington could use telepsychiatry within inpatient units or the two state psychiatric hospitals to increase their psychiatric capacity and more quickly and appropriately treat mentally ill patients.

3) In community-based facilities: Other settings can benefit from improved access to psychiatric providers including correctional facilities, outpatient facilities, schools, primary care offices, urgent care centers and FQHCs. By increasing the psychiatric capacity of community-based programs it is less likely for a person to reach psychiatric crisis that requires hospitalization.

While telepsychiatry is not able to create hospital beds, it is an advantageous way to bring psychiatric care where it is not readily available. Telepsychiatry can reduce the time patients spend awaiting evaluation and treatment that ultimately has a significant impact on patient care, the patient experience, and the general healthcare system.

I urge Washington to consider this new medium of care as they makes plans to address psychiatric boarding.

[2] Schumacher Group. (2010) Emergency department challenges and trends. 2010 survey of hospital emergency department administrators.
[3] Department of Health and Human services at Washington State Institute for Public Policy, Legislation Evaluation and Accountability Program Committee (from Infograph on
[5] Konrad, T. Ph.D., Ellis, A., M.S.W., Thomas, K., M.P.H., Ph.D., Holzer, C., Ph.D., Morrissey, J. Ph.D. (2009, Oct). CountyLevel Estimates of Need for Mental Health Professionals in the United States. Psychiatric Services, 60(10):1307-1314.

jamesvarrel1Dr. Jim Varrell

James R. Varrell, M.D. is the founder and Medical Director of the CFG Health Network and InSight Telepsychiatry, LLC. Dr. Varrell is American Board certified in Psychiatry and Neurology, and certified in American Academy of Child and Adolescent Psychiatry with a specialty in autism. Dr. Varrell has been at the forefront of telepsychiatry across the nation and continues to educate the medical community regarding the benefits of telepsychiatry through various presentations and forums where he has served as a panelist and presenter. Dr. Varrell recently spoke at the 2012 symposium on telepsychiatry at the American Psychiatric Association’s national meeting. Dr. Varrell preformed the nation’s first involuntary psychiatric commitment via a televideo unit in 1999. Today, Dr. Varrell still regularly performs telepsychiatry evaluations and manages a staff of telepsychiatrists who see and treat patients in ten states.


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