When I walk through my hospital’s emergency department, I’m sometimes overwhelmed by the number of people languishing there as they wait for help with a mental health issue, like the woman clutching her chest as if she’s having a heart attack but is really suffering from a panic attack. It’s her third time here in a week.

She is just one of the hundreds of patients who will be admitted this year to my emergency department in the Mat-Su Regional Medical Center in Palmer, Alaska, experiencing psychiatric emergencies.

Many stay in the emergency department for hours; some even stay there for a few days. The practice, called psychiatric boarding, occurs when an individual with a mental health condition is kept in an emergency department because no appropriate mental health care is available. It’s rampant around the country.

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Millions of Americans with mental health issues are not getting the care they need. It’s a crisis so profound that it is overwhelming emergency departments and the entire health care system. The causes? Too few outpatient resources and inpatient treatment options for mental health issues; separate systems for treating mental health and physical health; and a shortage of specialists able to respond to patients in the midst of mental health crises, to name just a few.

I believe hospitals can curb this trend by doing a few key things, beginning with improved collaboration.

Behavioral health emergencies by the numbers

The statistics are staggering: Nearly 1 in 5 U.S. adults — about 44 million — experiences mental illness in a given year, a number that is certain to increase. And it comes at a time when the demand for mental health professionals is outstripping the supply. For psychiatrists alone, a 2017 report published by the National Council for Behavioral Health estimates the shortage will be between 6,100 and 15,600 practitioners by 2025. That same report points out that lack of access to psychiatric services in hospital emergency departments is especially problematic.

In Alaska, where I work and live, the crisis is dire.

The Alaska Psychiatric Institute, my state’s only psychiatric hospital, followed the lead of many other state hospitals in the late 20th century to de-institutionalize the care of people with mental illness and increase community care. In 1990, Alaska Psychiatric Institute had 160 beds. Today, when fully staffed, it has 80 beds, with just 50 beds for patients experiencing acute episodes of mental illness. The recent publication of a report about unsafe working conditions at the institute prompted its director to resign.

The result of this downsizing and chaos? Patients needing inpatient treatment end up bouncing from group homes to acute-care settings, like the emergency department or, worse, end up in jail.

Jail and prison are now among the largest settings for mental health services, a final destination for individuals failed by the medical system. Yet neither correctional facilities nor emergency departments constitute the best therapeutic environment for people in the midst of mental health crises, and the care (or lack of it) they get there often leads to poor outcomes.

Given the consequences of inaction and insufficient resources, health care organizations need better tools, solutions, and integrated-care approaches so patients leave hospitals not just physically alive, but mentally thriving.

Understanding the underserved behavioral health patient

How did the emergency department become the epicenter for psychiatric care in so many states?

Part of the answer is the function of the emergency department in today’s health care system. I think of it as an overflow tank. When one part of the health care system fails, problems trickle down and come to rest in the emergency department. The tremendous fear and stigma associated with mental health makes the problem worse, as many patients fail to seek help at the onset of a mental health issue. There are financial barriers, too. Primary care doctors, for example, traditionally couldn’t bill for the treatment of a mental health disorder, though that is changing.

The effect is a surge in patients seeking providers who can “fix” or “help” them on demand in the emergency room. But the hospital emergency department isn’t designed to address ongoing behavioral health issues that require personalized, psychiatric interventions. When a patient isn’t an immediate threat to his or her community, they’re eventually discharged but left unchanged and unaided — and essentially ready to repeat the cycle.

Making matters worse is that many behavioral health conditions, such as generalized anxiety or depression, have physical as well as emotional and behavioral manifestations. The patient I mentioned at the start of this essay was so paralyzed by anxiety that she would regularly come to the emergency department with “chest pains.” We checked her symptoms every time, and every time her heart, lungs, and hormone levels were fine. We would assure her she did not have a life-threatening condition and release her. But the moment she got into the parking lot, she would again experience chest pains and rush back in to the hospital.

She spent so much time in the emergency department that she lost her job, housing, and friends. Yet because she didn’t meet criteria for inpatient hospitalization — she wasn’t suicidal — the cycle continued.

It finally took a trespassing violation at the hospital to land her in a local, progressive mental health court. Instead of being given jail time, she was instead paired with a probation officer who doubled as her personal counselor and who also set her up with supplemental professional help for ongoing therapy. The probation officer was able to talk her down when she felt overwhelmed by the compulsion to check into the emergency department. Today, she has a job, an apartment, and is a functional member of society.

Had she received a behavioral health intervention sooner, she would have been spared a lot of grief — and the health care system a lot of extra work and cost. Still, she is one of the lucky ones. Too many people linger for extended periods in the emergency department, the most expensive and hardest way for them to get the help they need.

Moving beyond silos

It doesn’t have to be like this. Individual health care providers can help change things by treating mental health conditions like any other disease process, instead of treating them like burdensome acute flare-ups that can be squashed and forgotten.

System-wide, when patients with psychiatric issues arrive in the emergency department, we need an easier way to transfer them to a higher level of care for psychiatric issues. Better coordination with mental health providers, even bringing such providers into the initial decision-making process, would speed treatment and free up emergency department resources.

There are efforts, such as the “Alameda Model” led by Dr. Scott Zeller, which create a separate psychiatric emergency department where patents can be stabilized and worked into a coordinated system to escalate their care as needed. The results of a 30-day trial of this approach were impressive: transferring patients from general hospital emergency departments to a regional psychiatric emergency service reduced the length of boarding times for patients awaiting psychiatric care by more than 80 percent compared to state emergency department averages.

New tools and technology can help improve collaboration between emergency and behavioral health providers to make sure everyone is on the same page. Mat-Su Regional Medical Center, along with most hospitals across Alaska, are part of the Collective Medical network (for which I am an unpaid member of the clinical advisory board). Through a digital interface, the network connects our hospital to other health care providers within the state and to other hospitals across the country. Patient information is aggregated, so when a patient enters the emergency department, the network pushes to physicians at the point of care real-time alerts on essential medical data, such as the patient’s history of psychiatric care and patterns of emergency department use. For my hospital, this tool has been a game changer.

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Expanding access to behavioral telehealth can help more people get the mental health care they need before having to resort to the emergency department. Through a virtual care platform, patients with transportation issues and other challenges can receive counseling at home more easily than if they were to wait hours for a psychiatric worker to conduct an initial consultation in person. Studies have shown that behavioral telehealth improves access to care and potentially decreases emergency department use.

The goal of medicine is to help people become happier, healthier, and more functional members of their communities. Having people with mental health issues cycle through the high-intensity, anxiety-inducing emergency room environment is not the way to do this.

We need to consider new ways to give health care workers real-time insights into the needs of psychiatric patients. We also need to consider better ways to “triage” psychiatric patients to more appropriate caregivers after they’re admitted to the emergency room. Finally, we need to be open to sharing data and best practices with each other so we can elevate the lives of our patients.

The better able we are to treat patients with mental and behavioral issues, communicate and collaborate effectively, and match patients with the appropriate resources outside of the emergency department, the better off our health system and our patients will be.

Anne Zink, M.D., is the medical director for emergency medicine at Mat-Su Regional Medical Center in Palmer, Alaska; the immediate past president of the Alaska chapter of the American College of Emergency Physicians; and an unpaid member of the clinical advisory board for Collective Medical.

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  • A few years ago I had been diagnosed withNon Hodgkins Lymphoma. During my Chemo treatment, I was given Prednisone 100 mg for five days then told to stop taking it. Doing this would throw me into a very deep depression, and end meat the Mercy of the Emergency room. Some times I would stay there for 2 or 3 days until there was a room for me. I would end up in a lock down facility. The underlying reason for my mental breakdown was Prednasone. I was not tapered off as is supposed to be. I will never take that medicine again. It does not matter if it is ordered on a tapered down dose. My medical records say that Prednasone is an allergy for me. Thank God that is all behind me.
    One time as I remained in the ER I was given pj bottoms that were way to big. On my way to the hall way bathroom, I fell flat on my face. No one heard me fall so basically urinated on the floor. When I was finally moved to A lockdown facility with a black eye from the fall. No one ever asked me what happened at the ER. The lock down I was admitted to was full of adicts Alcohol or Drug. I was told that I had to go the a newcomers meeting right there on the Unit. What a nightmare that experience was. BECAUSE the ER did not know what else to do with me. “I finally stood up to my Oncologist and told her that I can not take Prednasone ever again.

    • Ms Dolan,
      Your experience is horrific and not that unusual. Lots of people have negative reaction to Prednisone and other Steroids. Some people get suicidal form these drugs. Physicians pretend to be unaware of this problem… The facts are not in the advertising, and they are not allowed to track adverse events. It is horrific that they would put someone on Chemo in the Psych Ward, you are very lucky that you survived. The Medical Providers out sick people in the Psych Ward all of the time, it has to do with their insurance and ability to pay. They turn out people with serious mental health issues, if they cannot pay too.
      Healthcare is the US has a reverse incentive problem.

  • A few things that can help—integration of behavioral health into primary healthcare so that behavioral health therapists are available the same way and in the same place as a primary care provider, with psychiatric services available with screening. The model of mental health agencies isolated from other services is outmoded. If services are robust and available at the outpatient level, the need for psychiatric visits to the emergency room should be reduced. A good number people visiting the ED for psychiatric reasons can be served well by subacute settings with onsite staff and beds, with meals, groups and a safe recovery setting.
    People have to be able to afford inpatient and outpatient treatment and medication, and be able to access these regardless of ability to pay.

  • I am a reader of StatNews in its many categories of publication.

    This a.m. I read Dr. Zink’s thoughts on the status of today’s “psychiatric care” in the “wanting” U.S. approaches to experiential and behavioral anomalies in this model for diagnosing and offering treatments.

    I am a retired Clinical Health Psychologist, who taught and practiced in the
    health care field for some 40 years. I was able to witness evolution in the
    history, understandings, inter-professional battling, and range of treatments developed and offered to people in need.

    Care for people with aberrant experiences and behaviors evolved from the
    most primitive, near barbaric, through various theories of origins, struggles
    about professional dominance, and has currently found a predominant home in bio-chemistry.

    In the 20th century, now extending into the 21st, it would seem that the issues remain much the same. Dr. Zink’s article reflects – in my view – a continuation of all the history noted here, while many would argue progress made, while a foundation of consistency yet evades us. The issues are far from being a solution to our understandings and interventions.

    At the base – I humbly suggest – is the degree to which we are still at the
    beginning. I say this only to remind us all that the demons we face in health
    of mind and behavior really continue to allude us.

    Alex Kronstadt, Ph.D.
    Weston Florida

    • Therein lies the problem. An “expert’ with 40 years experience and no more insight than an engaged observer. Not even clever enough to ask how they personally participated in this nearly genocidal nightmare. No one asks what happened to those people they “treated” whether they were seriously “mentally Ill’ or just in situational crisis. No one asked about the long term outcomes, deaths, or even the ongoing stigma. I find this a little terrifying. If I could go back in time 40 years, I would tell the people I knew to avoid “treatment” at all costs. Back then finding marijuana in a teenagers rooms, or too much “talking Back” was a good enough reason for forced medication. Now we have children in Foster Care, or incarcerated at “Detention Camps” at our Border, forcefully medicated. I suppose in your comfortable retirement, you can look backs at the lies, deceptions, and Gas Lighting, and pretend you “helped.’ Thanks for your silence!

    • I disagree , respectfully…. there is a better way and some of us know far more than what most will learn in a classroom, but why is our knowledge less valuable? Science and scientist are alway innovating new thoughts, new ideas, new ways of doing things and most of us that dared to “think or colour outside the lines” we know a better way , we do .

  • Don’t let them fool you. There is nothing really new here, this have been going on for decades, and is only getting worse. This is the culmination of years of for profit healthcare models, pharma advertising and and nearly genocidal hatred for the sick or poor. These ER’s are also storing alcoholics, drug addicts, and denying care to actual sick people. The uninsured or under insured, are typically kicked out with nowhere to go either.

    Hospital Lobbyists at the behest of our broken healthcare system created this mess. One in a while one of the Pharma funded “Advocacy Groups” helps someone to give the appearance it can be done. Our local Hospital has a lot of Frequent Fliers, mostly people addicted to drugs and alcohol, who return repeatedly to the ER. The ER can bill for heart monitoring or other services, but not for their underlying health condition that probably triggered the drinking and drug use.
    A lot of these people were denied actual healthcare 2 decades ago, lost their jobs, and their family support,and chose to alleviate their symptoms with drugs and alcohol.

    Here is post fact America these people have been re-framed, and stigmatized, when they could not add to the Hospitals bottom line. Quite a few are traumatized by the lack of medical care, years ago, when it could have made a difference. Workplace Injuries, and even recalled Medical Devices are at the root of a lot fo these Er returns, only they are not supposed to be discussed. It was easier for the industry to paint them all as mentally ill, so they could deny the failed surgery. In many cases Surgeons and Hospitals took money from device and drug manufacturers to destroy the people that end up in the ER.
    They are Gas lighting us all. No attempt has been made to collect any objective data on why these situations continue to re occur.
    Our community recently has a young man with Schizophrenia kicked out of the ER and instead of looking at what led up to his death, they did a PR scam like this article here. The poor guy was shot 17 times by police in a Swat Style action. No one in the community even bothered to ask what happened, instead they did a Dog and Pony Show, with NAMI, a pharma funded patient advocacy group. It gets circular after a while, but all we have to do is follow the money, and ask, Who benefits.

    • Don’t be so negative Mavis. Blaming people would not get anyone anywhere. As suggested by JanCarol, implementing programs like ‘Open Dialogue’ could a long way in improving the system. The main thing is to get rid of the large influence of pharma when it comes to mental health (at many different levels).

    • kdn,

      Back in the 1970s I accompanied a Psychiatrist to a number of academic programs that were supposed to be “Thinking outside the Box.” Flash forward all of these years and things have gotten worse, much worse. Pro Public just did a horrifying story of one families ordeal with a clinical trial, and unethical researchers. Moat of the garbage published lately is not even based in science, it is barely discernible from marketing. I have had a particular set of circumstances where, it is so patently obvious, that there has been no improvement. Our Jails, ERs, and homless shelters are full of the “Mentally ill, many did not have serious Illnesses until they were traumatized stressed and abused. Publication like this have compounded the problem, since they run anecdotal nonsense, and Advertorials instead of Facts. There is plenty of blame to go around, and little recognition of the failures of whatever they call what they are doing. the really sick part of all of this, is that this is generational. the people they did not “help” years ago are having children of their own, and subjecting them to trauma and abuse. the real blame of course goes to the for profit business model, Neo Liberalism, and a lot of practitioners too corrupt or morally bankrupt, to have any idea where they went wrong. There is a fair bit or superiority, and sadism here too. We need a serious paradigm shift before there can be any improvement, and it might be too late. I have been tracking this nonsense for decades now, and thirty years ago they were promoting the same propaganda. These few self described innovative projects are usually PR Campaigns for the Hospital Industry. When they need a SWAT team to deal with one person with a mental illness after he is not only forced into homelessness but denied care by the local tax payer funded B.H Clinic, there is a problem. Clinics by religious groups so there is no oversight or expectation of improvement or decent outcomes, are not helping. Even children are being drugged, due to their race or economic circumstances, not a mental illness. Actually poverty is now a mental illness.
      Perhaps people should start paying attention before commenting at people they don’t know. it is a lot easier to have an opinion, when you have not seen this first hand over decades, or seen the way they are profiteering from the ignorance, deceptive marketing and nonsense like this. I know children whose lives are ruined, thanks to the approach presented here. Even if it does improve anything, it is not sustainable due to the Market Based Approach. There is nothing remotely new here.

    • You preach the truth Mavis. It is heartbreaking but we must TELL THE TRUTH. People are dying…slow deaths…isolated and alone…hopes broken. Enough!

  • When are we going to recognise that current treatment of “mental health” using DSM and drugging is making people worse?

    There are rebound affects from all of the psych drugs, causing blunting, akathisia, impulsiveness, restlessness, insomnia – many of which can escalate distress. Even when the drugs “work,” there are costs to health (diabetes, metabolic issues, dystonias, kidneys, liver, and adrenal) with long term use.

    But nobody knows how to get off of them. All medical treatment is about getting onto them. Nobody knows how to get off of them.

    kdh’s Friendship Bench is one possibility. Alaska had a Soteria House for people in distress. Open Dialogue involves the whole family, and works very well in community settings. Finland got their “schizophrenia” beds emptied using this technique.

    It’s the model that’s faulty. Add to that basic “diagnose and drug” model – the corporate profit motive – and yes. Broken system. Needs more than beds – needs a new way to look at mental and emotional distress without making it a “medical problem.” Medicalising it.

    It’s mental and emotional distress. Used to be, Aunties, and Grannies and communities helped people through hard times. We’re all too busy to do that now, even for our families.

  • Mental health patients do not need beds – what they need is a way to engage with the world as well as support and hope for recovery. Also, the provision of support/hope doesn’t have to come from medical doctors. A study published in JAMA demonstrated that a peer support program (called “The Friendship Bench”) resulted in greater benefits to patients than normal standard care – here’s the reference:

    Chibanda, D., et al. (2016). Effect of a primary care–based psychological intervention on symptoms of common mental disorders in Zimbabwe: a randomized clinical trial. JAMA, 316(24), 2618-2626).

    The current approach of dealing with mental health focuses on labeling people based on DSM checklists and assigning them medicines that are simply profit-driven. These medicines result in ’emotional blunting’ along with terrible long-term side effects. We also need to remember that stigma and discrimination exist when people distinguish and give labels to human differences that are associated with negative stereotypes. Also, labels give a sense of ‘permanency’ (to the so called ‘disorder’), disempower individuals, and take away hope for recovery.

    Organizing and providing peer support networks could go a long way in ensuring functional recovery of these patients.

    • That has been the Lie foisted on us for decades now. “Organizing” now consists of Pharma Funded organizations, with a clear agenda of supporting the industries profiting here. Per Support sounded really good too, but the system is too corrupt to even monitor that effectiveness of any of it. They hire people with drug dependency or other issues who use their Peer Support positions to exploit vulnerable people. Vulnerable mentally ill people are used by these sociopaths to find drug connections, and invitations to “Party.” I know of one “Peer Support Specialist” who drive here Client to parties for the Cocaine and Booze. That was while getting opiates form the clinic she worked for. Of course the Clinic had no method for reporting any of these concerned. Welcome to Post Fact America, where this stuff sounds great until you put it into practice.

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