Code Overdue: Psychiatric Care in the Emergency Department

Hartej Gill, PhD(c)


October 25, 2021

Emergency medicine clinicians and emergency departments offer first-line care for people requiring immediate medical attention. In the United States, there are more than 100 million annual ED visits.

At one time or another, many of us have found ourselves waiting for emergency care. The long wait times and delays in care have increased the likelihood of short-term adverse events and pose a significant barrier to receiving timely medical intervention. However, whether it is a broken arm or a life-threatening injury, the ED is the first — and often, only — option for rapid care.

This frantic pace juxtaposed with the long wait times is characteristic of people's perception of the ED, one embedded in popular American culture through shows such as Grey's Anatomy. The ED is typically portrayed as a frenetic and chaotic environment. However, emergency rooms have also become a first-line option for individuals requiring mental health care.

Between 2007 and 2016, approximately 10% of ED visits were for mental health or substance use–related disorders (SUD). In children, approximately 5% of ED visits were for mental health–related concerns. Notably, 15% of the mental health–related ED visits resulted in hospitalization or prolonged care. Over the past decade, the number of mental health–related ED visits has significantly increased. This may underscore the inaccessibility and lack of resources available for timely and efficacious outpatient mental health care.

Mental Health Care Emergencies

Due to the lack of capacity and availability of mental health care options, significant burden is placed on the ED for immediate intervention. A growing problem has since been worsened by the significant patient and economic burden brought by the COVID-19 pandemic.

In addition to significant limitations and extended wait times for non-COVID–related care, the risk factors for both mental health and SUD have increased under pandemic conditions. This includes increased life stress, socioeconomic burden, and decreased social interaction.

Similarly, in adolescents and children, increased social isolation has been a major challenge for important developmental milestones. Young adolescents use developmental and social milestones such as graduation, sporting events, and concerts as a mark of growing independence and individualism. The impact of the pandemic on social and developmental opportunities may contribute to the increase in adolescent mental health and SUD outcomes.

The presence of these risk factors has combined to worsen pre-existing mental health disorders and increase the likelihood of novel onset of disorders. Recent literature has shown an increase in the prevalence of mental health disorders and SUD during the pandemic that have led to higher risk for infection, hospitalization, and death in patients with mental health disorders.

Subsequently, a large number of individuals are left without adequate and timely mental health or SUD care. For example, in 2016, the National Survey on Drug Use and Health reported that only 12.7% of individuals with an identified need for treatment for SUD received adequate care within 1 year of accessing treatment. Of note, approximately 50% of patients visiting the ED for drug-related concerns report diagnosis of a SUD. Substance use–related disorders in youth are severely undertreated, with only 8% of individuals ages 12-17 meeting DSM-5 criteria for SUD receiving treatment each year.

For youth with SUD, the ED is generally their first and only point of contact for mental health treatment. It is evident that immediate action is required to improve the accessibility and effectiveness of outpatient care for mental health and SUD-related disorders. The ED should not be the primary available care option for psychiatric emergencies. This will inevitably contribute to increased economic burden and poor patient-reported outcomes.

It is clear that ED visits are a critical point of care for intervention and progression of mental health disorders. Often, follow-up care for mental health– and SUD-related emergencies are poorly defined and unclear. Data from the ED also demonstrate improved outcomes following timely and effective intervention from ED staff for patients with mental health–related emergencies. Improved treatment will begin with timely screening, patient referral, and effective interventions.

With the redirecting of resources to COVID-related emergencies, the need for early and effective intervention to avoid ED visits as a first point of contact is incredibly important. Novel policy changes should prioritize these for improving screening, intervention, and patient-reported outcomes.

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About Hartej Gill
Hartej Gill is a PhD candidate and researcher at the Canadian Rapid Treatment Center of Excellence and the Institute of Medical Science at the University of Toronto. He has expertise in mood disorders, investigating the etiology and pathophysiology of mental health disorders from both a clinical study and population health perspective, with over 50 peer-reviewed publications.


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