by Anthony T. Ng, MD*

Overcrowding of emergency rooms has become a major part of the national health crisis. The death of a psychiatric patient, Ms. Esmin Green, at the Kings County Emergency Room in New York is but one of the consequences of such overcrowding. As community mental health resources have become scarcer in the past several decades, individuals increasingly turn toward the emergency room (ER) for help with psychiatric crises. These visits may include mental illnesses that lead to risks of suicide, homicide as well as functional impairments. Some go to ER's to obtain psychiatric medication refills as they cannot get earlier appointments from their psychiatrists. A significant portion of patients present to ER's for psychiatric crisis with substance abuse issues, be it acute intoxication to chronic dependence.

Emergency rooms are stretched to the breaking point. There is limited physical space and limited staff, including mental health clinicians. People living in rural areas may have to travel long distances. All this results in dramatic increase in wait time in the ER's. A recent study in Health Affairs showed a 4.1% increase per year in ER wait time between 1997 and 2004, with ethnic minorities, women and patients in urban ERs waiting longer than other patients.

Patients coming to an emergency room for psychiatric reasons often report: fearfulness; sadness; sudden crying; suicidal thoughts; disruptive or agitated behavior; severe anxiety; an inability to work or function in some manner. Frequently a nurse sees them when they really need a doctor. Even when a psychiatrist determines they will be admitted, there are long waits. Esmin Green had been waiting all day - wearing only a hospital gown. Add another six hours before a bed is available and several more hours before someone actually gets to it, and tack on the long distance travel for people living in rural areas. If they have substance abuse or medical issues such as metabolic conditions, cardiovascular and neurological diseases, concerns of psychiatric patients may be minimized. Finally, there may be stigma for those seeking psychiatric emergency care. In the end, people can begin to wonder if they did the right thing by coming in.

Emergent psychiatric care is provided in two different settings, depending on their communities. Psychiatric care can be provided in a manner whereby patients are seen by non-psychiatric clinicians first and then by a mental health clinician as a consultant, which may or may not be a psychiatrist. After which, an appropriate plan for the patient will be made, including possible need for hospitalization.

The other setting is a psychiatric emergency service, such as a Comprehensive Psychiatric Emergency Program (CPEP), full time psychiatric staff evaluate, treat and even perform short term stabilization, i.e., several days. This is really important because what is the use of getting the evaluation if there is a dearth of programs?

Yet, there may be very few mental health outpatient resources to refer patients to, often a significant challenge for indigent or uninsured patients, or those with co-morbid medical or substance abuse issues. All of this is further complicated because hospital beds have been reduced markedly. The number of US inpatient beds for psychiatric patients dropped by two thirds, from 4 per 1,000 in 1964 to 1.3 per 1,000 in 1990.

Crisis
But, what defines a crisis? Patients often have difficulty identifying the severity of psychiatric crisis. Symptoms are often subjective and patients receive insufficient education from their providers. They are often told to go to the nearest hospital if it is an emergency, but what makes an emergency can be confusing. And what support can be initiated by patients to mitigate and lessen any crisis?

What can fix this crisis? It might seem logical to simply increase emergency services capacity. But that would be a very short term and poor solution. The change cannot only redesign programs but also requires a change in thinking from crisis management to crisis prevention. The solution involves a revamping and a creative programming of outpatient community resources, as well as more efficient use of inpatient resources. Additionally, the best way to manage any crisis is to prevent one from happening in the first place. Patients should be empowered to help devise and manage a crisis plan.

We also need to address ongoing stigma of psychiatry and the "mental" patient to ensure that they receive the most appropriate care when needed for psychiatric, substance abuse, medical, or a combination of the three. Psychiatric patients and their families continue to be discriminated against not only by attitudes but also by reimbursement for services. Patients will not seek care for a mental health crisis when they need to pay out of pocket for expenses. As such, their crisis often becomes so severe and impaired that no alternatives but hospitalization will be needed to help them.

• Advanced Directives: In the outpatient environment, how to handle a crisis should be addressed with patients before one occurs. Outpatient mental health clinicians need to discuss a crisis plan with their patients involves identifying risk factors, alternative coping skills and support resources in the event of a crisis. Clinicians should also discuss any role for advanced psychiatric directives similar to the general health directives and proxies. Patients can make a decision on what they would like done or not done to help them, and who they want to speak for them if they become incapacitated in any manner.
  
  It is important that psychiatric clinicians partner with patients when they are stable to determine what constitutes psychiatric emergencies, what are the factors that can lead to these emergencies, what support can be initiated by patients to mitigate and lessen any crisis. The crisis can be resolved with more intensive outpatient management. Clinicians should determine the benefits of hospitalizations, i.e., will the patient achieve a level of stabilization that will prevent a repeat crisis.

• Crisis Diversion Facilities: Crisis residence and alternatives should be created and adequately funded so that patients can receive crisis service stabilization in the least restrictive environment. While more inpatient psychiatric beds at hospitals are unlikely to be created, the more appropriate use of pre-existing beds needs to occur. For example, not all patients who have been identified in crisis need to be admitted. Often times, these risks are short term and can remit quickly.
• Innovative Alternatives: ER services should look for innovative ways to serve the psychiatric needs of patients. In areas where there is a lack of psychiatric resources, or services are remote, the use of telepsychiatry may be an option. ER physicians are often willing to work collaboratively with psychiatrist to help manage psychiatric crisis and hotlines can be used to help manage some of crisis. Mobile crisis teams may also be a possible treatment modality to manage crisis. The use of peer advocates on site at the ER may help minimize stress on not only patients but also staff.

Certainly ongoing training between psychiatry and emergency medicine staff will greatly enhance the recognition and management of psychiatric issues in ER's. At the system level, local mental health authorities should collaborate with other human services, law enforcement, and substance abuse agencies among others to assess the severity of local overcrowding and the appropriate use of services for mental health crisis.

There is unfortunately no quick fix and one-size-fits-all solution to reducing waiting times and overcrowding. It requires collaborative efforts between all stakeholders. There needs to be innovative solutions to identify alternatives for crisis prevention and crisis management that will minimize the use of emergency services and hospitalizations, and provide that stabilization in the least restrictive environment. Only when we can achieve complete mental health parity can we as a society hope to address the psychiatric needs of our communities.

Also read:
Disaster Mental Health by Anthony T. Ng.

*Dr. Ng is President of the American Association of Emergency Psychiatry (AAEP). To find more information, visit www.emergencypsychiatry.org.