Treating mental illness in the ED

With nowhere else to turn, mental health patients are flooding emergency departments. Teaching hospitals are figuring out how to better care for them — and keep them comfortable while they wait for long-term services.
Emergency department with patients and personnel in two bayss

Three years ago, a patient grappling with suicidal thoughts came to the University of North Carolina (UNC) Medical Center’s emergency department in Chapel Hill, North Carolina, for help. Her parents made the 11-hour drive from Michigan before the patient was even seen by a psychiatrist.

And that wasn’t out of the ordinary. At that time — before the hospital implemented a major overhaul of its emergency behavioral health services — patients were spending up to 48 hours in the emergency department before being evaluated.

Since then, the hospital has created a division of emergency psychiatry, complete with its own psychiatrists, psychiatric social workers, and nurse practitioners. Patients now receive care within 2 hours.

UNC Medical Center is just one of many teaching hospitals across the country whose emergency departments (ED) are packed with people facing mental health problems. In fact, one in every eight. emergency department visits in the U.S. is related to a mental disorder and/or substance use issue. What’s more, ED visits related to mental health and substance-use issues increased more than 44% between 2006 and 2014, the last year for which data is available, with suicidal ideation visits growing by nearly 415%.  

“Suicide rates and attempted suicides have continued to increase,” says Robert Trestman, MD, PhD, chair of psychiatry at the Virginia Tech Carilion School of Medicine, who serves on two councils for the American Psychiatric Association. “Given the lack of capacity in the mental health care delivery systems, a substantial volume continues to fall on the emergency departments as the de facto primary care,” he notes. “I don’t see an end in sight.”

“Given the lack of capacity in the mental health care delivery systems, a substantial volume continues to fall on the emergency departments as the de facto primary care.”

Robert Trestman, MD, PhD
Virginia Tech Carilion School of Medicine

Teaching hospitals across the country have been hard-hit, acting as safety nets for those with few options. But they also have been working to tackle the problem. Solutions include making the ED safer and more comfortable for those with mental health conditions, setting up special emergency psychiatric units, increasing telepsychiatry services, and hiring more staff to accommodate growing numbers of patients.

“I think that’s the case everywhere, and certainly locally we’ve been adding more resources,” Trestman says. “That simply wasn’t needed a half dozen years ago. Now it’s critical.”

The source of the problem

The influx of mental health patients to emergency departments is a problem that starts in the community and is spurred largely by poor or nonexistent insurance coverage for mental health conditions and a shortage of psychiatrists.

For people who are struggling with mental health issues, obtaining insurance coverage can be one of the biggest barriers to getting help, says Al Sacchetti, spokesperson for the American College of Emergency Physicians. That’s partly because it can be tough for them to obtain and hold down a job that provides comprehensive benefits.

Yet even with insurance, paying for care can still be an uphill battle. A national study published by Milliman, a risk management and health care consulting company, found that behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care, which means that it’s more costly for patients.

The 2008 Mental Health Parity and Addiction Equity Act improved coverage for mental health care and addiction treatment, but the law only mandates that if insurance companies do provide this coverage, it must be equal to coverage for other health issues.

And insurance is just a piece of the puzzle. It also can be difficult for patients to find an available psychiatry appointment.

According to a recent report by Merritt Hawkins, a physician search and consulting firm, 77% of U.S. counties face a serious shortage of psychiatrists, and the AAMC projects that there will be a shortage of as many as 3,400 psychiatrists by 2032. That’s fueled by several factors, including rising numbers of people seeking treatment as awareness of mental health problems has grown. What’s more, large numbers of psychiatrists are approaching retirement: More than 60% of practicing psychiatrists are over the age of 55, according to AAMC data.

Swamped psychiatry practices may have long waits for appointments or may even turn away new patients. According to one study of psychiatrists’ availability in Boston, Massachusetts; Houston, Texas; and Chicago, Illinois, the average wait time was 25 days for a first visit. About one in five psychiatrists were not accepting new patients.

The result is an influx of mental health patients coming to emergency departments, and ED physicians can only do so much.

“You can control whether you can aggressively manage patients. You can control what you can do with a psych patient in the confines of the ED,” Sacchetti says. “What we can’t control is what happens outside the ED.”

Shortage of inpatient beds

For those with nowhere else to turn, the emergency department is the only available source of medical help. But once they check in, a new challenge arises:  getting into an inpatient facility.

In fact, the lack of inpatient beds has led to a common practice of “boarding” mental health patients in the ED — putting them up for several days while hospital staff scramble to find them additional resources. According to a 2015 Emergency Medicine Practice Research Network poll, 70% of emergency physicians surveyed reported psychiatry patients being boarded on their last shift.

“I’ve seen cases that have been over a week,” says Trestman, who notes that emergency departments can be tough for people with psychiatric conditions. “They tend to be very busy and very noisy.”

The root of the problem goes back several decades, says Manuel Pacheco, MD, chief of the emergency service for the department of psychiatry at Tufts Medical Center.

“With all these pressures of decreased beds, the insurance issues, what I always tell my residents is, ‘Just think back to what’s best for the patient.’ ”

Manuel Pacheco, MD
Tufts Medical Center

What was once considered a spectacular achievement of the John F. Kennedy administration, the Community Mental Health Act of 1963, turned out to be a spectacular failure, according to Pacheco. “The goal of the act was to try to shift people from the state hospital system.” Instead, many mentally ill patients were deinstitutionalized with nowhere to go. “The state hospital programs were well-funded, but that money wasn’t put into community resources like community health centers,” Pacheco says.

All this leaves EDs struggling to figure out how to best help mental health patients.

“We do a lot of stabilization. You have to always remind yourself to see the patient in front of you,” Pacheco notes. “With all these pressures of decreased beds, the insurance issues, what I always tell my residents is, ‘Just think back to what’s best for the patient.’”

While they wait

Emergency department physicians have no control over how long a patient may wait for a bed, either in their hospital or elsewhere. But while patients wait, EDs are working to create environments that are more comfortable and appropriate for those with psychiatric conditions.

At Massachusetts General Hospital, the ED’s acute psychiatric unit is undergoing a massive expansion. The current number of beds — six — is not nearly enough, explains Emergency Department Vice Chair Ali Raja, MD, MBA. One recent afternoon, for example, there were 14 psychiatric patients waiting in the ED. Once the project is completed, the unit will have 20 beds.

In the meantime, staff set patients up in recliners rather than gurneys or hard chairs. It’s important to provide psychiatric patients with various forms of comfort, Raja explains, because they may become more agitated if the environment is too frenetic.

“In the emergency department itself we can try to make the time period when they’re with us more comfortable and pleasant,” he says. “We now give them three meals a day with the understanding that these patients may be here for three days.”

Often, mental health patients need extensive attention and monitoring as well.

“There’s a very real concern for self-harm,” Raja notes. “You can learn to hide razor blades in a cell phone. That didn’t happen once — that’s happened a handful of times.”

“You can control whether you can aggressively manage patients. You can control what you can do with a psych patient in the confines of the ED. What we can’t control is what happens outside the ED.”

Al Sacchetti
American College of Emergency Physicians

At the University of California, Los Angeles, David Geffen School of Medicine’s emergency department, only two rooms are designed specifically for behavioral health patients, according to Greg Hendey, MD, chair of emergency medicine.

“If we’re well beyond our capacity, sometimes we have patients in hallways with individual sitters to sit with them,” Hendey says. Meanwhile, he notes, the hospital has hired a full-time case manager who is constantly on the phone with facilities trying to find beds for the waiting patients.

Solutions for the future

As the flood of mental health patients coming to the ED continues, teaching hospitals are taking steps to get patients the care they need.

At University of North Carolina Medical Center, the ED is providing a range of mental health emergency services to two small hospitals through telemedicine to help ease the load there.

“We provide patient consult, medication recommendations, follow-up care for as long as they are in the ED, and recommendations for disposition through telepsychiatry,” says Jane Brice, MD, MPH, professor and chair of emergency medicine at the University of North Carolina School of Medicine. UNC also is in discussion with five other hospitals about launching similar services.

Other academic medicine institutions are also providing various forms of telepsychiatry services. The University of Virginia Medical School, for example, partners with outpatient clinics to offer remote support for appointments that can help prevent patients coming to the ED.

Additionally, hospitals can connect patients with case managers and community health workers who may find needed services for them. For example, The George Washington University Hospital and MedStar Georgetown University Hospital connect patients to the ACT (Assertive Community Treatment) Program, a DC-based team of mental health professionals who help those with mental health issues who are under-insured or uninsured.

Other potential solutions include the creation of a “bed czar” responsible for keeping track of available beds or a shared directory that allows staff to see which facilities have room for patients.

Despite the problems associated with higher numbers of mental health patients in the ED, Sacchetti says there is a silver lining: It’s a sign that efforts to destigmatize mental illness are working.

“In general physicians are better educated about the presentations of mental health,” Sacchetti says. “The other part of it is there’s not as much stigma associated with it now. If you had a problem before, you hid it. You’re seeing more people coming in with it. They’re not running underground now.”