Opinion: I work in a psychiatric ER. I’m watching the system fail people in real time
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- Ashley Andreou, a third-year psychiatry resident in New York City with a Yale health policy master's, works as one of only two overnight psychiatry providers in a psychiatric emergency room.
- A 20-year-old patient with autism and intellectual disability — anonymized as "J" — was boarded in the ER for 121 hours after his mother dropped him off for punching her; she repeatedly promised to take him home "tomorrow" but never did, citing years of resistance to residential placement.
- The clinical team administered 50mg of intramuscular Thorazine — a 75-year-old antipsychotic — and placed J in a four-point manual restraint at 6:58 a.m. after he punched a technician, despite Andreou noting J does not have psychosis.
- The de-escalation ended with Andreou, three security guards, and J singing "Old MacDonald Had a Farm" from Spotify while a nurse injected the Thorazine — a moment Andreou contrasts with her medical school vision of "diagnosis, treatment, discharge."
- The psychiatric ER functions as a de facto detox center, winter shelter, and caregiver respite — what Andreou calls a "final harbor" for patients the social services system has "failed to catch," with restraint orders audited by the State Office of Mental Health.
Why it matters: A 20-year-old with autism was boarded 121 hours in a psychiatric ER not for acute psychiatric care but because his family had no respite, residential options, or in-home support. The case illustrates how psych ERs have become default holding cells for a collapsed community disability system, forcing clinicians to chemically sedate patients for want of basic services.
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