Among the substantial gaps in mental health care in the United States, access to emergency psychiatric and crisis services is greatly limited. In addition to a lack of available care in these areas, patients who do access treatment in the emergency department (ED) often face long wait times before treatment is initiated.
Findings from 2 recent studies explored the current state of emergency psychiatric and crisis care in the US. In a study published in January 2022 in Psychiatric Services, researchers examined data from the National Mental Health Services Survey (N-MHSS) to identify trends in the availability of psychiatric emergency walk-in services and crisis services in public and private US mental health treatment facilities between 2014 and 2018.1
They found that 42.6% of facilities did not offer mental health crisis services during the study period, while 33.5% offered emergency walk-in services and 48.3% offered crisis services. The results also showed a 15.8% decrease in walk-in services (1.52-1.28 per 100,000 US adults) and a 7.5% decrease in crisis services (2.01-1.86 per 100,000 US adults). The authors noted geographic disparities in service availability, especially near US borders and coasts, suggesting that “policy efforts would be valuable for ensuring equitable service availability,” they wrote.1
A study published in May 2021 in Pediatrics revealed disparities in pediatric psychiatric treatment in the ED, Nash et al examined trends in the length of stay (LOS) among children aged 6 to 17 years seeking mental health care in the ED compared to those seeking ED care for nonmental health reasons.2
Their analysis of data from the National Hospital Ambulatory Medical Care Survey (2005-2015) showed that rates of prolonged LOS increased from 16.3% to 24.6% (LOS >6 hours) and 5.3% to 12.7% (LOS >12 hours) for mental health ED visits, while LOS for nonmental health visits remained stable. Additionally, the odds of LOS greater than 12 hours were significantly higher among patients of Hispanic ethnicity (odds ratio [OR], 2.74; 95% CI, 1.69-4.44) seeking mental health care in the ED.2
In a similar vein, an American Psychiatric Association (APA) Resource Document3 published in 2019 noted the increasing prevalence of patients waiting for psychiatric care in the ED for hours or days after the need for admission or transfer has been made — a practice referred to as “boarding.” A 2015 study found that the odds of boarding were 4.78 times higher among psychiatric patients compared to nonpsychiatric patients.3
“The substantial rise in prolonged LOS for mental health ED visits and disparity for Hispanic children suggest worsening and inequitable access to definitive pediatric mental health care,” Nash et al concluded.2 “Policy makers and health systems should work to provide equitable and timely access to pediatric mental health care.”
We interviewed the following experts to learn more about emergency mental health care needs in the US: Kimberly Nordstrom, MD, JD, emergency psychiatrist at the University of Colorado Anschutz Medical Campus in Aurora, associate clinical professor of psychiatry at the University of Colorado School of Medicine in Denver, and lead author of the APA resource document mentioned previously; and Luke Kalb, PhD, assistant professor at the Kennedy Krieger Institute and the Johns Hopkins Bloomberg School of Public Health in Baltimore, and first author of the above-mentioned 2022 study published in Psychiatric Services.3,1
Broadly, what is the current state of emergency mental health care in the US, and what are believed to be the reasons for gaps in care?
A full continuum would allow for increased intensity of outpatient services for those in need. Also included would be crisis hotlines and warm (peer support) lines, mobile crisis teams, walk-in centers, withdrawal management centers (“detox”), crisis stabilization units, and EmPATH (Emergency Psychiatric Assessment, Treatment, and Healing) units or psychiatric emergency services.
Those communities that have some or all of these services in place tend to be at capacity, especially with reduced capacity related to COVID — decreased staff, quarantine beds, etc. Many communities do not have a robust continuum and rely solely on EDs for urgent and emergency issues. To make matters worse, many EDs do not have access to behavioral health specialists.
Dr Kalb: The current health care system is strained beyond capacity due to COVID-19. Health care workers are exhausted and burned out. This is especially true for emergency health care providers, given they have been at the frontline of COVID-19. This does not bode well for the emergency mental health care system, in which the ED sits at the entryway.
Over the last 20 years, visits to the ED for mental health reasons have been increasing, so the ED sits at the confluence of COVID-19 and increasing acute mental health visits. This is problematic since the ED is a medical, not mental health, setting. Numerous studies have shown there is a lack of mental health expertise in this setting, along with a lack of inpatient beds for discharge. This leads to long ED waits, which may end up resulting in a discharge home. This problem has arisen because the ED has been the “de facto” safety net, which needs to change. The good news is that change is coming, but probably slower than we need.8
What are some of the key measures needed to significantly improve emergency mental health care in the US?
Dr Nordstrom: There are several: The first is to ensure better training for emergency physicians. Unfortunately, most emergency medicine residency programs require little, if any, training in psychiatry. This leaves emergency physicians at a disadvantage, especially if they end up working in rural areas, where there are few resources.
Previously, it was noted that telepsychiatry was not being utilized as much as it could be to help fill in gaps and allow people in rural areas to receive similar care as those in urban areas. COVID-19 has helped move this forward and telepsychiatry has been more widely adopted. More people are able to receive care before they have an emergency, and more people are able to see an actual psychiatrist when they present to an ED. There is still room to grow here, though.
In large, urban centers, one is more likely to find the full continuum for urgent and emergent behavioral health care, but this is not the case in smaller cities and towns. States need to continue to invest in the full spectrum of care to allow people to receive the level of care necessary and divert from EDs that may not be able to meet their needs.
Dr Kalb: I think my study1 identifies 2 key gaps: First, we need places for people to seek immediate care outside of the ED, and walk-in services provide that opportunity. Second, having crisis services that go out into the community to reach those in need are important as well. While my study looked at “crisis services,” it was very heterogeneous, capturing a mixture of clinic-based and community-based services, so I couldn’t tell which exact services were provided. Either way, the data clearly shows that outpatient mental health facilities across the US are not reporting an increase in the delivery of services between 2014 and 2018.
What are recommendations for providers about how to implement and advocate for change in this area?
Dr Nordstrom: As noted in the American Psychiatric Association resource document on the boarding of mentally ill patients in the ED, each professional (physician, therapist, etc.) has the ability to advocate within his or her professional society, as well as individually on a local or state level.3
One way to advocate locally is to get all interested parties together to discuss the issue. This has happened in several large cities. Physicians, hospitals, community mental health centers, police, and local government have come together to help shape emergent behavioral health care. It is necessary to work across systems.
Dr Kalb: Many of the changes that need to be made are at the funding level, including reimbursement by insurers and state, as well as federal grants. Without funding for training and delivery of care — such as an increased number of providers — it’s tough for providers themselves to make changes. The issues are systemic and require efforts at the advocacy and political levels. These data show how important organizations like the National Alliance on Mental Illness (NAMI) are.
What are other ongoing needs in terms of education or research regarding this topic?
Dr Nordstrom: In terms of education, I noted that emergency physicians need specific education; this should also be applied to emergency nursing. Unlike emergency physicians, emergency nurses do receive training in mental health but do not necessarily receive specific training in verbal de-escalation, motivational interviewing, and trauma-informed care. These 3 particular pieces could truly make a difference in the care individuals receive while in an ED. Regarding research, the Coalition on Psychiatric Emergencies held a research consensus conference to help determine priorities for behavioral emergency research and produced an executive summary.9
Dr Kalb: Much more research is needed. This is just a high-level overview of the national landscape. We need much more in-depth research on the models that work best and for whom.
Are there any additional relevant points you would like to mention?
Dr Nordstrom: You may have noticed that I switched from focusing on “mental” health care to “behavioral” health care. This broader language encompasses care sought by those suffering from substance use disorders (SUD). As part of the mental health community, I suggest that we take a whole-person, trauma-informed approach and focus on the larger needs of individuals.
In psychiatry, there is a subspecialty dedicated to treating those with SUDs, and general adult psychiatrists may have received only nominal training specific to SUDs. It is incumbent on all professionals working in the field of behavioral health to be able to identify and treat SUDs and not just typical mental health disorders.
1. Kalb LG, Holingue C, Stapp EK, Van Eck K, Thrul J. Trends and geographic availability of emergency psychiatric walk-in and crisis services in the United States. Psychiatr Serv. 2022;73(1):26-31. doi:10.1176/appi.ps.202000612
2. Nash KA, Zima BT, Rothenberg C, et al. Prolonged emergency department length of stay for US pediatric mental health visits (2005-2015). Pediatrics. 2021;147(5):e2020030692. doi:10.1542/peds.2020-030692
3. Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LLM. Boarding of mentally ill patients in emergency departments: American Psychiatric Association Resource Document. West J Emerg Med. 2019;20(5):690-695. doi:10.5811/westjem.2019.6.42422
4. AAP, AACAP, CHA declare national emergency in children’s mental health. American Academy of Pediatrics. Published October 19, 2021. Accessed online February 14, 2022. https://publications.aap.org/aapnews/news/17718
5. Children’s Hospital Colorado stands with partners – declaring national pediatric mental health emergency. Children’s Hospital Colorado. Published October 20, 2021. Accessed online February 14, 2022. https://www.childrenscolorado.org/about/news/2021/october-2021/partners-declare-national-pediatric-mental-health-emergency/
6. Horvath A, Castor J. Update: Surgeon general issues advisory on the country’s youth mental health crisis. Rocky Mountain PBS. Published December 8, 2021. Accessed online February 14, 2022. https://www.rmpbs.org/blogs/news/colorados-health-leaders-and-advocates-call-on-state-lawmakers-to-fund-youth-mental-health-services/
7. COVID-19 disrupting mental health services in most countries, WHO survey. World Health Organization. Published October 5, 2020. Accessed online February 14, 2022. https://www.who.int/news/item/05-10-2020-covid-19-disrupting-mental-health-services-in-most-countries-who-survey
8. Brind’Amour K. The new emergency department — for behavioral health. Pediatrics Nationwide. Published October 1, 2020. Accessed online February 14, 2022.9. Wilson MP, Shenvi C, Rives L, Nordstrom K, Schneider S, Gerardi M. Opportunities for research in mental health emergencies: executive summary and methodology. West J Emerg Med. 2019;20(2):380-385. doi:10.5811/westjem.2019.1.39260