The Issue of Managing Mental Health Crisis in Emergency Departments

Suicide has been in the news more and more recently. The suspected suicide of Washington State’s quarterback Tyler Hilinski has rocked the college football world. Just a few weeks ago YouTube star Logan Paul outraged his viewers for filming a man who had hung himself in Aokigahara forest (also known as “suicide forest”) in Japan. The United States is no stranger to suicide. On average, there are 123 suicides per day. Sadly, the United States is plagued with a weak infrastructure to manage mental health crises such as suicide. This becomes particularly in focus when looking at emergency departments  and how mental health crisis is managed there.

The rates of people using EDs for mental health reasons are on the rise. An estimated one in eight ED visits is for a mental health reason. Recent data by the Agency for Healthcare Research and Quality showed that of all the ED visits in the US in 2013, over 900,000 were related to suicidal ideation. The number of people presenting to EDs nationally for suicidal ideation increases nearly 12 percent each year.

What accounts for this ever increasing number? To start, the nation is experiencing a shortage in psychiatric providers. People seeking mental health services either cannot find any or enter an extremely long wait list. As a result, many individuals with mental illness find themselves in EDs. ED providers are then expected to intervene with a high volume of patients with mental illness while not understanding how to properly care for them. And this leads to subpar treatment.

Individuals with mental illness typically come to EDs in crisis. However, the crisis can easily become escalated instead of alleviated. ED staff members with mental health training are limited in numbers. As a result, patients often end up sitting alone with a security guard or other nontherapeutic staff members watching them with minimal interaction. In these situations, patients have reported feeling as though they were treated more like prisoners than hospital patients.

The very environment of EDs can be overwhelming, further contributing to patients’ symptoms. Patients can quickly end up receiving medication to calm them down instead of other de-escalation strategies being tried first. Often, patients would prefer not having these medications. Even worse, patients can quickly end up in restraints, which can escalate the situation.

Patients say they feel as though there is no one to talk to and that care is not patient centered.  They feel their case is not appropriately triaged and that all mental health conditions are treated the same even though they are very different. The lack of concern and consideration is interpreted by patients as disrespect.

Patients with primary issues involving mental illness can spend many hours in the ED waiting to be transferred to an inpatient psychiatric unit. This is called “boarding” and this issue has been increasing in frequency. Studies have found that patients with mental illness typically end up being boarded in EDs hours longer than patients with medical conditions. It is not uncommon for a patient to wait up to a few days for a bed in a psychiatric unit.

This issue is multifaceted though. Low reimbursement rates from insurance companies and a shortage in psychiatric providers have caused many inpatient units to close down. This in turn decreases the number of available psychiatric beds.

Mental health disorders are no different than medical ones. However, patients with a mental health condition feel they are met with a more negative attitude than they would if they were having chest pains or their blood sugars were high. After all, both are linked to biology. It’s just that mental illness is less understood than many of the medical illnesses. This is also where the stigma comes in.

Providers in EDs can argue that they were not meant to be mental health care providers. After all, they are trained to manage significant traumas and save people’s lives from acute medical emergencies. And no one is taking that away from them. But when will we start seeing mental illness as any other illness that deserves equal consideration? When will medical providers start to embrace the need to provide quality care to mental health patients? After all, suicide is consistently one of the top 10 leading causes of death alongside a variety of medical conditions.

Rates of suicide are high and are increasing each year. The mental health care system is broken. Unfortunately, initiatives rolled out as part of Trumpcare may cut funding of mental health resources even further. This will in turn lead to even more people with mental illness going to EDs for stabilization. It is time to shift the focus from a YouTube star using suicide for exposure to helping the world finding ways to support and help those who are most vulnerable. It’s time we give people in mental health crisis a fighting chance at recovery, whether it’s through the words we use to fight stigma or by improving healthcare policy to enhance mental health resources. If not feasible, the least we can do is improve care once they make it to their option of last resort: the ED.


Dr. Michelle Heyland is an assistant professor of community, systems, and mental health nursing at the Rush University College of Nursing, a psychiatric nurse practitioner, and a Rush Public Voices fellow.

Morning Consult welcomes op-ed submissions on policy, politics and business strategy in our coverage areas. Updated submission guidelines can be found here.

Morning Consult