While the COVID-19 pandemic certainly impacted Americans’ mental health, ED visits for psychiatric needs had been steadily climbing for years beforehand. In 2007, mental health visits comprised 6.6 percent of all ED visits. By 2016, that number almost doubled to 11 percent.^1,2 In a 2015 poll, 70 percent of emergency physicians reported that psychiatric patients were boarding on their last shift, with more than half reporting average boarding times of up to two days.³

During the pandemic, mental health issues played an even larger role in emergency medicine. Rates of anxiety and depression significantly increased, with 40 percent of U.S. adults reporting they struggled with mental health or substance abuse in June 2020, and 10.7 percent reporting they had seriously considered suicide.⁴ While overall ED visits declined because of the pandemic, mental health visits remained disproportionately high.^5-7

Now that ED visits have stabilized closer to pre-pandemic volumes, it is too soon to have a precise understanding of the current state of ED visits for mental health issues. One large review suggests that population-level mental health has rebounded close to pre-pandemic baselines, with only a slight increase in depression.⁸ This is not necessarily good news; if we’re right back where we started prior to the pandemic, we are still not in a good place.

It is clear to practicing EM physicians that caring for patients with mental health issues remains a pressing concern. Too many patients wait far too long in our EDs to receive necessary mental health care, causing needless suffering for both patients and caregivers. That’s why ACEP is prioritizing mental health as a key focus for 2023, dedicating significant resources to the issue.

Behavioral Health Care Resources You Should Know About

One simple way you can mark Mental Health Awareness Month is by making sure you know about the helpful tools and resources available to assist with emergent behavioral health:

• ACEP’s Mental Health & Substance Abuse Information Papers web page is a very useful collection of articles offering insight into several pertinent ED practices, including:⁹
  • Recent reviews of ED psychiatric care
  • Advice on medication therapy during psychiatric emergencies
  • Assessment of psychiatric safety in suicidal patients
  • Practical solutions to boarding of psychiatric patients
• ACEP has relevant clinical policies and policy statements associated with ED Psychiatric Care:
  • Critical Issues in the Diagnosis and Management of Adult Psychiatric Care in the ED¹⁰
  • Adult Psychiatric Emergencies¹¹
  • Pediatric Mental Health Emergencies in the ED¹²
• ACEP’s advocacy efforts related to behavioral health care are documented on its website and will be recapped in person at the 2023 Leadership & Advocacy Conference.¹³
• The Coalition on Psychiatric Emergencies (CPE) is made up of a group of leaders in emergency medicine, psychiatry and patient advocacy who are focused on improving the treatment of psychiatric emergencies for patients and emergency providers.¹⁴
• ICAR2E is a point of care tool for managing suicidal patients in the ED.¹⁴

Behavioral Health is among the top priorities for ACEP President Chris Kang, MD, FACEP, and ACEP’s Board of Directors. ACEP members who attended recent Council meetings can attest to the number of resolutions created around emergent behavioral health care. From these resolutions, several working groups were formed. Multiple objectives are being addressed by ACEP committees and will result in new and/or updated ACEP policies and publications over the next several months. A new clinical policy, “Critical Issues in the Evaluation and Management of Adult Prehospital or ED Patients Presenting with Severe Agitation,” is open for member comments until May 25, and the following resources are currently being updated:

• Pediatric Mental Health Emergencies in the ED
• Adult Psychiatric Emergencies policy statement
• ACEP Well-Being Resource Guide

ACEP is working closely with many partner organizations, including the American Psychiatric Association, the American Medical Association, the American Association for Emergency Psychiatry, the National Alliance on Mental Illness and more to assure that recommendations and solutions align with our on-going efforts in the area of emergent behavioral health care.

Thoughts from ACEP President Christopher S. Kang, MD, FACEP

Dr. Kang

The COVID-19 pandemic has indelibly disrupted our individual lives, local and national communities, and clinical practices. Throughout it all, emergency departments, staffed by you and your teams, remained open and steadfast. However, emergency medicine cannot continue to shoulder most of the health care system as various inadequacies persist and grow. Mental health patients have increasingly complex needs, fewer places for support, and board longer in the ED than medical patients. Left unaddressed, mental health care for patients and ourselves will challenge, even threaten, our security and humanity as well as the future well-being and trajectory of our workforce and specialty. Your individual and collective participation and collaboration are essential. And it starts with your willingness to learn and do more at the bedside and in your hospitals and sharing your stories, innovations, and successes.

Note: If you’re involved in significant innovations to address emergency mental health care, ACEP’s EM Practice Committee would love to learn more and highlight successful models. If you are willing to be featured, please send an email to sshahid@acep.org with a brief description.

Listen in: Dr. Kang will talk about behavioral health and physician mental health as our guest on the May episode of ACEP Nowcast.

It’s also important to recognize the tools that exist in our communities of care; several are as close as a simple keystroke. Many EM clinicians across the country recognize the power of existing community information exchanges such as FindHelp and UniteUs that can provide lists of available community resources such homeless shelters, behavioral health treatment centers, sobering centers and substance use disorder organizations, amongst other things. Access to relevant information on these platforms is often free of any charge, is easily available to the general public, is targeted by zip codes, and provides a wealth of information on available resources such as hours of operation, contact information, and resource website access.

Many of the individuals for whom we provide emergency mental health care have ongoing issues. In many cases, these individuals are connected with a number of additional practitioners within our communities of care, and if not, they probably should be. It’s easy to focus on the resources that we lack for ideal treatment, such as immediate psychiatric consultations or immediate housing placement. It’s worth the effort to recognize what resources of care exist within each of our communities and extend an outreach to understand them better and to proactively create plans of action together.

It’s likely you’ll be surprised at the amount of great work community-based organizations are conducting and the resources they can provide. These may help tremendously within the post-discharge world. There is a strong effort among most state and managed care organizations to increase outreach with high-risk individuals through the efforts of community health workers and others, often with a focus on lived experience within hired staff. Alternative options of care are growing rapidly within communities around the country, and it behooves us to connect with and be knowledgeable of the resources they can offer.

What’s Next?

Much work has already been done to address mental health emergencies, but much more remains. Our committee is working on additional articles related to behavorial health concerns, including best practices in risk stratification, the initiation of medication, and more.

American EDs are responsible for managing millions of visits for mental health issues. Working together, EPs can and will continue to improve the care these patients receive, both inside and outside of the ED.

Dr. Enguidanos is the chair of ACEP’s Emergency Medicine Practice Committee (EMPC). He is Founder/CEO of Community Based Coordination Solutions.

Dr. Miller is the Chief Medical Officer of Vituity. Dr. Miller leads an EMPC sub-committee focused on mental health issues in the ED. 

References

1. Moore BJ (IBM Watson Health), Stocks C (AHRQ), (AHRQ). OP. Trends in Emergency Department Visits, 2006-2014. HCUP Statistical Brief #227. Agency for Healthcare Research and Quality; 2017.
2. Theriault KM, Rosenheck RA, Rhee TG. Increasing emergency department visits for mental health conditions in the united states. J Clin Psychiatry. 2020;81(5).
3. ACEP Emergency Medicine Practice Committee. Practical solutions to boarding of psychiatric patients in the emergency department. does your emergency department have a psychiatric boarding problem? American College of Emergency Physicians website. Published 2015. Accessed April 26, 2023.
4. Czeisler M, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the covid-19 pandemic—united states, June 24-30, 2020. Morb Mortal Wkly Rep. 2020;69(32):1049-57.
5. Anderson KN, Radhakrishnan L, Lane RI, et al. Changes and inequities in adult mental health-related emergency department visits during the covid-19 pandemic in the us. JAMA Psychiatry. 2022;79(5):475-85.
6. Holland KM, Jones C, Vivolo-Kantor AM, et al. Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the covid-19 pandemic. JAMA Psychiatry. 2021;78(4):372-9.
7. Lucero AD, Lee A, Hyun J, et al. Underutilization of the emergency department during the covid-19 pandemic. West J Emerg Med. 2020;21(6):15-23.
8. Sun Y, Wu Y, Fan S, et al. Comparison of mental health symptoms before and during the covid-19 pandemic: evidence from a systematic review and meta-analysis of 134 cohorts. BMJ. 2023;380:e074224.
9. Mental Health & Substance Abuse Information-Papers. ACEP website. Accessed April 26, 2023.
10. Nazarian DJ, Broder JS, Thiessen MEW, et al. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2017;69(4):480-98.
11. Adult Psychiatric Emergencies. American College of Emergency Physicians website. Accessed April 26, 2023.
12. Pediatric Mental Health Emergencies in the Emergency Department. American College of Emergency Physicians website. Accessed April 26, 2023.
13. Mental Health Advocacy. American College of Emergency Physicians website. Accessed April 26, 2023.
14. Mental Health and Substance Use Disorders. American College of Emergency Physicians website. Accessed April 26, 2023.