Treating Mental Illness in the Emergency Department

Researchers estimate as many as one in eight ED visits by adults and one in 10 ED visits by pediatric patients are linked to mental illness and substance use disorders in the US. And those numbers are rising, according to a pair of recent studies.

According to a study published in the journal Pediatrics earlier this year, 28 percent more young people are arriving at emergency departments seeking help for mental illness and substance use disorders, with the largest increases among teenagers (54%), African Americans (53%), and Hispanic (91%) patients.

Likewise, a 2017 study conducted by the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality found a 44 percent increase in adult ED visits related to mental health and substance-use issues.

The reasons more psychiatric patients are coming to the ED are complicated, a combination of too little in-network insurance and too few psychiatrists, according to the Association of American Medical Colleges. And once they arrive, many emergency departments struggle to treat patients with increasingly complex psychiatric disorders. Among adult ED mental health/substance abuse visits, the number of admissions rose 31.8 percent. And according to the Pediatrics study, visits last an average of three hours (1 in 5 last more than six hours), with only 17 percent of patients actually seeing a mental health professional.

But what can be done?

According to Luther Kalb, PhD, a researcher at the Kennedy Krieger Institute at the Johns Hopkins University Bloomberg School of Public Health in Baltimore, Maryland, and lead author of the Pediatrics study, more mental health services are needed to keep patients from going to the ED.

“Using the ED as a psychiatric crisis center needs to change,” Kalb told Rachael Zimlich, RN, BSN of Contemporary Pediatrics. “We need to look at expanding other crisis treatment options such as walk-in crisis care centers, telepsychiatry, and mobile crisis treatment. We also need to study these interventions as well to make sure they are evidence based. We need to find new ways to get to people in times of need where they are at, rather than rely on the ED. The ED is really a medical, not a mental health, treatment setting.”

Others believe EDs need to be better equipped to help patients suffering from mental illness and substance abuse disorders. One such model is the emergency Psychiatric Assessment, Treatment & Healing unit, or emPATH unit. emPath units are hospital-based outpatient programs where patients with acute mental health crises can be evaluated, treated, and observed. Disposition is then determined from within the emPath unit rather than the general ED.

According to Denise Brown, M.D., who serves as chief strategy officer for Vituity, a physician led and owned multispecialty partnership that follows the emPath model, patients seen in an emPath unit are treated in “a safe space designed to calm and stabilize patients in behavioral health crises.” Brown describes the three pillars of emPath as 1. a calm environment, 2. de-escalation, and 3. immediate access to a psychiatrist, even if that means via video.

Telemedicine also is being used by the University of North Carolina Medical Center’s ED to provide a range of mental health emergency services to two small hospitals.

“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.

Looking to Congress

Programs like emPath and UNC’s telepsychiatry are just two of many possible opportunities that could be funded through a bill currently moving through both the House and the Senate to help emergency departments effectively treat patients with mental health and substance use disorders. “Improving Mental Health Access from the Emergency Department Act” (S. 1334/ H.R. 2519) was drafted by the American College of Emergency Physicians and, if passed, would “provide critical funding to help communities implement and expand the programs that work best for them.”

Specifically, ACEP says the bill would do the following:

Expedite transition to post-emergency care through expanded coordination with regional service providers, assessment, peer navigators, bed availability tracking and management, transfer protocol development, networking infrastructure development, and transportation services;
Increase the supply of inpatient psychiatric beds and alternative care settings such as regional emergency psychiatric units; and,
Expand approaches to providing psychiatric care in the emergency department, including telepsychiatry support and other remote psychiatric consultations, peak period crisis clinics, or creating dedicated psychiatric emergency service units.

ACEP also has partnered with the American Foundation for Suicide Prevention (AFSP) to develop a mental health and suicide prevention national awards program. According to ACEP, the new program will improve care in two ways:

By highlighting existing innovative suicide prevention solutions.
By developing an online-based suicide risk assessment and treatment tool to better guide the delivery of emergency suicide prevention services. The tool will be offered to emergency departments throughout the country.

Learn More

For more information about the increasing number of ED visits for mental illness and substance use disorder, check out the following resources:

“Trends in Psychiatric Emergency Department Visits Among Youth and Young Adults in the US” by Luther G. Kalb, Emma K. Stapp, Elizabeth D. Ballard, Calliope Holingue, Amy Keefer, Anne Riley for Pediatrics in April 2019, Volume 143 / Issue 4.
“Mental Health By The Numbers” from the National Alliance on Mental Illness.
“Trends in Emergency Department Visits 2006–2014” from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality.
“Treating mental illness in the ED” by Lindsay Kalter for AAMC News on September 3, 2019.
“ED visits for mental health crises on the rise” by Rachael Zimlich, RN, BSN for Contemporary Pediatrics on May 28, 2019.

For more information about emPath units, check out the following resources:

“EmPath: Stopping the dehumanization of behavioral health patients in emergency departments” by Denise Brown, MD, for Stat on July 2, 2019.
“EmPATH Units as a Solution for ED Psychiatric Patient Boarding” by Scott Zeller, MD, for Psychiatry Advisor on September 7, 2017.

For more information about “Improving Mental Health Access from the Emergency Department Act” (S. 1334/ H.R. 2519) and other ACEP efforts to address mental illness in the ED, review these resources: