Heart attacks, strokes, trauma, surgical emergencies, life-threatening infections and many other acute conditions are problems that emergency medicine physicians are well-resourced to solve. A problem they cannot solve — but one that patients and providers face daily — is our nation’s broken system for addressing mental health crises.
Across the country, individuals with severe psychiatric symptoms are brought to emergency departments (EDs) by family, friends, health professionals and law enforcement officers. Sometimes — such as after a drug or medication overdose — these individuals require a thorough medical evaluation and in these cases an ED is the right location. But often, people are brought to the ED because they were unable to access adequate care leading up to their crisis — and because there was nowhere else to turn once it began.
Why? There are several layers to the problem. The 1960s witnessed a massive reduction in public psychiatric hospital beds, often referred to as “deinstitutionalization.” Although there had been an intention to replace these hospitals with community-based mental health resources aimed, in part, at intervening earlier in the course of psychiatric illness and averting hospitalizations, development of these services did not keep pace with the need.
Also, most health care payment systems separated coverage for mental illness and substance use disorder treatment from other health care services — and made insurance coverage for psychiatric care far less robust. Separating these payment systems disincentivized screening and early intervention in primary care settings, made it less feasible for multispecialty medical groups to include psychiatric practitioners, pushed mental health providers away from participation in insurance systems, and rendered inpatient psychiatric services unsustainable for many hospitals and health care systems.
As a result, many patients now experience worsening psychiatric symptoms that go unchecked by routine care. When those symptoms culminate in a mental health crisis, community-based crisis-intervention services are often lacking, and when psychiatric hospitalization is finally the only safe option, inpatient psychiatric beds are often unavailable. Unfortunately, many who suffer from escalating psychiatric symptoms must use the ED as their crisis-intervention center — and when their care needs outstrip ED capabilities, they often remain there waiting for an available psychiatric bed.
It was already difficult for many patients to obtain mental health care prior to the COVID-19 pandemic, and over the past two years, an already overwhelmed system has become even more difficult to navigate. Accessing outpatient care at clinics and practices has become even more challenging and getting access to psychiatric care in hospitals and residential treatment centers has become nearly impossible at times–particularly for those in our communities already dealing with inequity with access to health care and social support services.
When patients experience a psychiatric crisis due to the natural course of their illness, unusual stress, inadequate social support systems or an inability to access intensive services earlier, they are usually brought to an ED. If a patient is unable to address their own basic needs or is a danger to themselves or others, they are often placed on an involuntary psychiatric hold — usually necessitating transfer to a secure psychiatric facility for further evaluation and treatment. These placements are difficult to find. Some patients may wait for days to be transferred to a facility that can deliver the care they need.
During that waiting period, teams of emergency medicine physicians, consulting psychiatrists, nurses, social workers and security staff manage patients’ most serious symptoms as well as they can with crisis intervention, medication and — when needed for safety — physical restraints. At best, these interventions maintain safety and prevent worsening of symptoms, but they do little to reverse the downward trajectory of illness or prepare individuals to function stably outside of a hospital setting. The ED environment — often busy, loud and brightly lit — is well suited for its intended primary purpose but is not designed to promote recovery from severe psychiatric illness.
Patients who require intensive psychiatric treatment sometimes wait for days in EDs pending transfer to more suitable facilities. There are not enough psychiatric hospital beds and treatment resources — gaps that can be largely attributed to insufficient funding and the failings of health care reimbursement processes. Creating more psychiatric inpatient beds is a part of the solution, but we also need broader action to develop and sustain adequate preventative and emergency mental health resources.
Our health care system has systematically marginalized patients with psychiatric illness, and this needs to end. Psychiatric illness is a condition like diabetes or asthma, yet acute treatment is not as readily obtained as it is for other serious medical conditions. ED patients with heart attacks are taken to a catheterization lab within 90 minutes. Patients with surgical emergencies proceed quickly to the operating room. While these conditions sometimes present a more imminent risk of death if not treated immediately, patients with mental illness also pay a significant cost as a result of delayed care: Adults with serious mental illness have a life expectancy that’s 10 to 25 years shorter than their healthier peers.
Reversing decades of neglect will take time and considerable political will. A necessary first step is for payers — public and private — to re-examine which services they cover, how they reimburse providers, and how they might better integrate systems for supporting psychiatric care within the larger health care system. We cannot truly expand access if mental health care continues to be viewed and treated as less important and is not adequately reimbursed. It is time to reconstruct our system so that mental health and addiction care are seen as equals with other forms of health care. Until then, EDs — however unsuitable they may be for intensive psychiatric treatment — will continue to be used by patients who have no other options.
Dr. Maria C. Raven (MD, MPH, MS, FACEP) is a practicing emergency physician and the chief of emergency medicine at UCSF Medical Center. She is professor and vice chair in the UCSF Department of Emergency Medicine. She researches the intersection of medical, behavioral and social needs in the emergency department.
Dr. Daniel F. Becker is professor of clinical psychiatry at UCSF. He serves as vice chair for strategy in the Department of Psychiatry and Behavioral Sciences. He is also the interim vice chair for Adult Psychiatry, as well as interim vice president for Adult Behavioral Health Services at UCSF Health.