Checking into the ED for a psychological complaint
When a person comes to the emergency department (ED) with suicidal thoughts or another mental health state that could be a threat to themselves or others (ex. extreme paranoia, homicidal thoughts, mania, etc.) the processes is simple. They change into paper scrubs and their clothes and belongs are locked in a secure closest, returned upon their discharge from the hospital. A hospital staff member sits outside of (or just inside) the person’s ED room conducting constant observation—which includes observing the patient at all times and recording their location and general behavior every 15 minutes. The constant observation is to ensure that the patient does not try to hurt themselves, try to leave, or try to hurt anyone else during their ED stay. Many people who check in for psychological evaluation are not allowed to leave the hospital until their mental condition has been cleared by a psychologist, meaning they are forced to stay in the ED until a doctor says that they will be safe returning to society. Patients suffering from psychological conditions that require more treatment than the ED can provide remain in the ED until a bed in a specialize treatment facility (or in the hospital psychology unit) opens.
One way to define “a national mental health crisis” in the US
When I think of a mental health crisis in the US, I think of all the people stuck in the ED waiting for a psych evaluation and then waiting for a bed in a facility that specializes in psychological treatment. I think of the patients who remain on lockdown in the ED for 100s of hours because if they leave they might knowingly or accidentally hurt themselves or someone else. These patients have no other safe place to wait for an in-patient bed. I think of the people who come to the ED and, even under the watchful eye of our staff, try to kill themselves. I think of the people who end up in restraints, literally tied to a bed, because their condition escalates to the point that they try to escape, attack hospital staff, or harm themselves. To me, the mental health crisis in the US is that we don’t have enough 24-7 services and specialized treatment facilities to keep patients with mental health conditions out of the ED. To me, mental health is just like any other aspect of health. We need to bolster our programs to help prevent acute mental health problems, but we also need adequate mental health treatment programs for those struggling with psychological conditions. The crisis, I think, is a lack of preventative care and readily available treatment, not the existence of diseases.
The ED does welcome mental health patients as we do all patients, but the ED is not equipped to find long-term solutions for any health condition. It is true that the ED can help with acute symptoms, which is all some patients need for a short period of time, but we don’t have a calming environment nor do we have the staff to provide intensive treatment for mental health conditions. We serve as a gatekeeper to specialized treatment and as a place to go when there is nowhere else to go. Just like the ED is not an appropriate place to perform and recover from surgery, it is not the right place for those who need in-depth evaluation or long-term treatment. The ED was designed to keep patients for ideally a few hours or, at most, for part of a day before sending them home or to an in-patient facility. But, what happens with some of our gravely ill psychological patients is that they must stay in the ED for days, even weeks, because there are no openings in specialized facilities.
Using the ED as a long-term home for people suffering from psychological conditions is neither therapeutic for them nor is it a cost-efficient design of the health care system. We need more mental health treatment facilities in the US. We need more programs designed to help those coping with mental health conditions manage their symptoms at home. We need more people going into the psychology fields and social work. In summary, we need to dedicate more resources to mental health in the United States. I think to do that we need to start by acknowledging how many people struggle with mental health and how weak or absent our treatment options currently are for those people. Next, we need to make mental health a budget and policy priority at all levels of government and in private health care systems. Right now, EDs are serving as the catch-all. They are not the solution. While the ED might be the right place for folks in any kind of acute health crisis to go initially, the ED only works if there are specialists and specialized facilities to refer our patients to once we’ve identified the sustained medical care they need. It’s times we prioritize mental health as we have heart health, lung health, and cancer-free health so that no patient is held in the ED because they have no other safe place to go.