SAN FRANCISCO – Not too long ago, a 42-year-old homeless man could not leave the Los Angeles County Hospital because he was too heavy.
M. Alexander Otto/MDedge News
Dr. Katherine Camfield
He had been admitted on a 72-hour involuntary psychiatric hold because he was suicidal; he had a history of severe depression and had made several attempts in the past. He had few social connections and had come in covered in lice after sleeping outdoors for months. He was mobile, but barely so, with the help of a walker.
He was cleaned up and medically stabilized at the hospital, but when it came time to transfer him to a psychiatric facility, no one would take him because he was morbidly obese, with a body mass index (BMI) of 53 mg/m2.
“We noticed this had happened with other patients. It wasn’t just this one case, so we” decided to take a closer look, said Katherine Camfield, MD, a psychiatric resident at Los Angeles County Hospital.
She and her colleagues called 43 inpatient psychiatric facilities in L.A. County. It turned out that 41, more than 60% of the total and including both public and private facilities, had weight restrictions. Staff members at the remaining two facilities were unsure.
For 2 hospitals, it was a BMI above 50; for 17, a weight above 350 pounds; and for 6, a weight above 300 pounds. Three had a limit of just 250 pounds. Others decided on a case-by-case basis. About 10% of the people put on psychiatric holds at the L.A. County Hospital weigh 250 pounds or more and therefore would not meet the weight limits at many facilities.
Some hospitals cited concerns about staff injuries from moving – or trying to calm – a large patient. Others said they did not have lifts and other specialized equipment or that their beds could not handle the weight. Others did not really give a reason.
County hospitals “are not a very therapeutic milieu; staff and nursing aren’t necessarily trained for unstable psychiatric patients,” Dr. Camfield said at the American Psychiatric Association annual meeting.
“Honestly, having a mental illness alone increases your risk of obesity, and then we give a lot of medications that increase the risk” even more. “It’s a vicious cycle,” and one that raises the issue of discrimination, although “whether these routine denials to access psychiatric hospitalization violate antidiscrimination laws is unclear,” she said.
She and her colleagues plan to take a deeper dive into the issue, to find out how widespread the problem is, and the reasons behind it. They are also interested in cost; “a county facility has limited resources; are they being misallocated because these patients are stuck in the hospital?” Dr. Camfield wondered.
The homeless man never made to a psychiatric facility. He was put on antidepressants and stayed in the county hospital for 20 days, until he was no longer suicidal. He then was transferred to skilled nursing facility.
There was no external funding, and Dr. Camfield had no disclosures.