By Bram Duffee, PhD, EMT-P
As first responders tackle more complex calls, they highlight that mental healthcare is a growing concern that often falls on their shoulders. In the “What Paramedics Want in 2024” report, based on the EMS Trend Survey, 62% of respondents reported patients in mental health crises have a high or very high impact on their communities [1].
That impact is frequently seen in the emergency room, where many hospitals face an overwhelming influx of patients with psychiatric concerns that must be monitored [2]. EMS providers also see this strain extending beyond healthcare facilities through direct contact with the homeless. One study showed that 42% to 80% of all homeless suffer from an existing mental illness [3].
First responders regularly encounter individuals who are unable or unwilling to follow prescribed medication plans, with substance abuse further complicating their situations. This scenario is especially critical for homeless veterans battling PTSD, who require specialized interventions [4, 5].
In the late 1960s and early 1970s, the United States underwent a significant shift in mental health care policy known as deinstitutionalization. This movement emerged from a growing concern that psychiatric hospitals were both costly and inhumane. They often housed individuals for extended periods with little hope of reintegration into society [6]. The advent of new psychiatric medications offered an alternative, enabling many patients to manage their conditions outside institutional settings [7].
California was at the forefront of this transformation, enacting the landmark Lanterman-Petris-Short Act in 1967. This legislation sought to end the inappropriate, indefinite and involuntary commitment of individuals with mental health issues, aiming to balance the necessity of treatment with the safeguarding of civil liberties [8]. The Act set a precedent and inspired similar reforms across the nation, reshaping state policies to prioritize community-based care and patient autonomy.
A recent Supreme Court decision in Grants Pass v. Johnson has significant implications nationwide, permitting communities to fine, ticket or arrest individuals living unsheltered, regardless of the availability of adequate shelter. This ruling determined that the “cruel and unusual punishment” clause of the Eighth Amendment does not prevent local governments from penalizing people for living outdoors [9]. As communities grapple with the mental health crisis, questions arise about whether such measures can effectively address underlying issues or merely displace vulnerable populations, like how cities manage homelessness during major events like the Super Bowl or Olympics.
In an interview with Krystal Gage, a former paramedic and now practicing attorney at VG Law Group, she explained, “These laws are intentionally left somewhat vague to allow each community the flexibility to implement necessary safety policies, but every area has different bottlenecks that prevent mental health patients from getting the care they need.”
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EMS approaches to serving the community
As the “What Paramedics Want in 2024" report indicates, nearly half of first responder respondents report using alternate destinations for mental health patients [1]. This shift reflects the growing need to relieve pressure on the current system. Bottlenecks are strained when the community responds to the problem: give the homeless food and it increases their time on the streets. Jail the homeless and the criminal justice system gets overwhelmed. Bring the patient to the hospital and they sit in an emergency department waiting on placement.
Alternate destinations, such as specialized shelters, mental health facilities or substance abuse treatment centers, can provide care and support. However, these solutions require adequate funding, coordination and policy support. The Grants Pass v. Johnson decision underscores the urgent need for communities to reassess and innovate their strategies for helping those with mental health issues and those who are underhoused. This ruling invites reflection on past experiences with deinstitutionalization, reinforcing the importance of compassion and sustainable solutions in policy-making.
One potential step forward is expanding EMS responsibilities through community paramedicine, a model that effectively bridges care gaps for vulnerable populations by enabling paramedics to engage with at-risk individuals in non-emergency settings. Over the past decade, this approach has demonstrated its capacity to improve community health outcomes by providing targeted support and alleviating the pressure on traditional emergency services.
Policymakers play a pivotal role in this transformation by crafting strategies that seamlessly integrate these services into existing healthcare systems, ensuring a coordinated response tailored to the specific needs of each community.
REFERENCES
1. What Paramedics Want in 2024 EMS Trend Survey
2. Derlet, R. W., & Richards, J. R. (2000). Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Annals of emergency medicine, 35(1), 63-68.
3. Zhao, E. (2022). The key factors contributing to the persistence of homelessness. International Journal of Sustainable Development & World Ecology, 30(1), 1–5. https://doi.org/10.1080/13504509.2022.2120109
4. Richards, J., & Kuhn, R. (2023). Unsheltered homelessness and health: a literature review. AJPM focus, 2(1), 100043.
5. Fischer, P. J., & Breakey, W. R. (1991). The epidemiology of alcohol, drug, and mental disorders among homeless persons. American psychologist, 46(11), 1115.
6. Yohanna, D. (2013). Deinstitutionalization of People with Mental Illness: Causes and Consequences. Virtual Mentor,15(10):886-891. doi: 10.1001/virtualmentor.2013.15.10.mhst1-1310.
7. George, P., Jones, N., Goldman, H., & Rosenblatt, A. (2023). Cycles of reform in the history of psychosis treatment in the United States. SSM-Mental Health, 3, 100205.
8. Gomes, S. (2010). The Lanterman-Petris-Short Act and the effects of deinstitutionalization on the mentally ill. California State University, Long Beach.
9. City of Grants Pass v. Johnson, 144 S. Ct. 2202, 219 L. Ed. 2d 941 (2024)