By Zainab Ahmed
Psychiatric care in the Emergency Department is all-or-nothing and never enough. Often, legal holds are the only intervention available, and they rarely are therapeutic. Upon discharge, our patients are, once again, on their own.
The ED acts as a safety-net for a failing health system, one that places little value on mental health services, either preventative or follow-up. The demand for acute psychiatric care is high; however, EDs have little physical capacity for psychiatric patients.
Triaging in the Emergency Department centers around vital signs and mental status — alert or comatose. Training is focused on resuscitation, and resources are allocated to traumas over therapy.
One patient was found at the middle of an intersection in the desert. The paramedics reported about 200-300 milliliters of blood loss on arrival from a self-inflicted arm injury and her blood pressure was low en route. Her mental state was altered, but it was unclear if it was from a potential overdose or hemorrhage.
Eventually, she received a unit of blood and her blood pressure and mental status improved. An hour into her laceration repair, I asked the patient what had happened. She said her social security income had abruptly ended, she was evicted, and she was still grieving the death of her mother. She told me she had done this before and was “bad at coping.” I asked her if she followed up with a therapist or a psychiatrist; she said she could only see them once a month because they were “understaffed.” By this point, we had moved her from the trauma bay to a side hallway. She was no longer the center of attention and didn’t have to be. Her emergency had been addressed.
To the extent that it is provided, psychiatric care in the Emergency Department centers on whether a patient meets “hold” criteria, i.e., if they are a danger to themselves, others, or are deemed “gravely disabled.” In other words, a hold, also known as involuntary commitment, is reserved for patients in crisis, usually from lack of coordinated outpatient care. These patients undergo a 72-hour involuntary stay and are watched, restricted, and medicated. Such holds are carceral in nature; they are often deployed by law enforcement and amount to little more than confinement.
Given the scarcity of available inpatient beds, most of these patients are “boarded,” or held in the ED, for their 72-hours of involuntary commitment. But training in psychiatry among ED staff is limited to learning how to de-escalate “the agitated patient.” Staffed ED physicians are often at the frontline of care but, due to the specialized nature of medical residency training, have very little formal preparation in dealing with mental health crises.
Typically, chemical sedation is the extent of our “therapeutic” role, and more often than not, does less for the patient and more for maintaining departmental workflow. Terms like “mania” and “psychosis,” and medications like olanzapine and haloperidol are dispensed with confidence, but not always with due deliberation. Our patients decompensate before us and we exacerbate their crises with inadequate care and lack of attention.
With rampant boarding, it is not unusual to have multiple psychiatric patients to sign-out to the incoming team: “55-year-old male with suicidal ideation. Homeless. Medically cleared. Pending board and transfer.” Individual patient cases begin to blur as their hours in the ED add up. Residents often inherit psychiatric patients that have been there for days.
Other patients simply are sent home. A patient with schizophrenia was brought in by her parents. She did not want to be admitted to the hospital. The patient exhibited capacity, the ability to communicate a choice, understanding, appreciation and reasoning. Her DSM-5 diagnosis did not interfere with her with her ability to care for herself and she did not pose a danger to herself or others. Ultimately, she was “cleared” by psychiatry. Her parents remained concerned and asked: “What would it take for her to be placed on a hold?” She could not establish outpatient care, and a hold would violate her autonomy. We negotiated for them to return if things worsened, whatever form that might take.
The Emergency Department is ill-equipped to deal with our current mental health crisis. Boarding is detrimental and involuntary commitments are far from therapeutic. Mental health does not get its due in residency training, leading to coercive rather than curative care. However, there is insufficient attention paid to why Emergency Departments are forced to function as make-shift mental health facilities — fragmented and inaccessible outpatient treatment. A sustainable solution requires not only reforming the emergency room but ultimately, building a continuum of care, ranging from stable and supported housing to free and accessible therapy.
Zainab Ahmed, MD is a resident in Emergency Medicine at UCLA. Views and opinions expressed are those of the author and do not represent affiliated institutions.
