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.

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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  • The best explanation, summation, and suggestions for dealing with this true ED Crisis that I have ever read! Congratulations Dr. Zink, and I hope it gets spread far and wide!!

  • We have a mentally ill President. Nothing is done to treat him. His right to be crazy is much more dangerous than some one the police drags in to the ER because they didn’t find cause to arrest.
    This country is unable to recognize serious mental illness. When treating a cancer one removes the tumors. When treating mental health we need too remove the crazies from power first.

  • There are other concerns that need to discussed, too. For example, federal law requires people with mental health issues to be treated in the least restrictive environment possible.
    SCOTUS has also said that people with mental illnesses have a constitutional right to refuse treatment even when under judicial holds. I call this a Psych Miranda Warning “You have the right to remain crazy.”
    So, even when we treat and get them stabilized, we can’t keep them stabilized because they stop treatment. This further increases the demand.

  • Dr Zink, Thank you for your reporting. However, where is the voices of those treated and have you done an in-depth study of why Dr Sidney Eolfe was so forceful in his takedown of the institutional structures?
    Yes the system is not only broken but corrupted from various streams.
    I would suggest you read up on Dr Loren Mosher and his professional history. I would also ask you to talk to survivors of the system. And no a specialized ER is not the answer. Trauma care and respite centers. Peer support and also check up on Bessel van der Klerk work and Robert Whittaker writing and research.
    And yes you are correct, it doesn’t have to be this way.

  • I have run a psych ER here in Philadelphia, next to the ER in a general hospital. It can work well. I would have fired Nurse Ratched if I could.
    Suggestions: telemedicine including to the lower 48, if your state medical board will facilitate licensure; lobby for changes in the funding of medical education to train more psychiatrists and pay us enough to pay off our loans; loan forgiveness ditto; CME; and obviously more beds, including in general hospitals for acute care.

  • Great article. Should mention that breaking down silos means $$$ too. If an outservice group can care for folks in street and prevent $1000 worth of ER VISITS will the folks paying for ER share 40% of the averted cost to sustain, expand and incentivize the outpatient service? No ? then I’ll see you in the ER.😳

  • “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.”

    Thanks for sharing your very enlightened view from the health care perspective. I am not a health professional, but I think we have to start with de-stigmatizing mental health issues. If your tooth hurts you see a dentist, if your skin is itchy a dermatologist. If your head hurts no one should be ashamed or fear being labelled for seeking mental health support rather than waiting for crisis intervention or when it’s to late.
    I think so much of the substance abuse, homelessness, violence and obviously suicides we see in our society are the result of mental health issues. We need to speak openly about these problems so that others recognize and feel more comfortable coming forward to address their problems without the fear of being labelled. As soon suggested, I agree that yoga and mindfulness practices would be helpful in the early stages for some to avoid the tragic outcomes we keep reading about when these poor people suffering from mental health problems conditions escalate.
    We are curing cancer in our lifetime, why are people ashamed to say they are depressed, or due to some chemical/genetic imbalance suffering in silence with schizophrenia or bi-polar conditions.
    Many of these conditions can be treated with the right medication. No one is ashamed to take ask for an aspirin if they have a headache. Why should any mental health condition be different.
    Maybe better education for the general public of the signs and symptoms would be a good place to start the conversation to help peel back the stigma of shame from mental health problems.
    Articles like yours Doctor will also hopefully help start a conversation about the use of our limited health care resources and the inefficiency of the current model in treating mental health patients in an ER environment.
    Opening everyone’s eyes to this problem in our society is a start.

  • “Create a separate psychiatric emergency department.” These already exist and they are just as bad as being in the regular ER, just more like jail. “Regional psychiatric emergency service,” Sounds like a another dump that nobody is going to pay for. “A virtual care platform,” for a patient that is hallucinating, paranoid, or suicidal? Sounds to me like you just don’t want them in your ED. I’m so completely unimpressed.

  • My son went in to er this past week for mental health. I reported nurse said she ought to work as a prison nurse. Mental health loved ones are no different then others. I hope it helps mental health hospital told me keep complaining maybe we will get somewhere. Thanks

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