Psychiatric Patients: The ED Not the Best Place during Crisis

As a psychiatrist, what is your advice for patients suffering a psychiatric crisis after hours? A common practice is to record a voice mail message that tells the patient to hang up and either call 911 or go to the ED. But is that the wisest course of action? Could it be that the ED is not the best place for psychiatric patients in crisis?

Psychiatric Times contributor Dr. Scott Zeller made a compelling case in an August 2018 article taking up this very question. He began by acknowledging that psychiatric patients are likely to follow voicemail advice in the midst of an emergency. He went on to explain that psychiatric patients are rarely treated in emergency departments. Instead, they are usually held just long enough to get them transferred to another facility.

Zeller points to statistics that say psychiatric patients who do make it to the emergency department are 2.5 times more likely to be admitted to an inpatient facility compared to those patients presenting with only physical problems. That is quite a disparity.

EDs Not Properly Equipped

A big part of the problem facing modern psychiatry is a lack of available treatment facilities. To start with, EDs are just not properly equipped to handle psychiatric crises. ED doctors are not trained in psychiatry. They are primarily internists with advanced knowledge of trauma. Any knowledge they do have in psychiatry is limited, at best.

Another thing to consider is the dwindling number of beds for psychiatric patients at inpatient facilities. According to Zeller, the number of total beds throughout the U.S. fell some 95% between 1955 and 2005. Where U.S. facilities used to have as many as 340 beds for every 100,000 people, that number is now down to 17 beds.

The obvious result here is that there are fewer beds for patients of all kinds. Moreover, available beds are likely to go to patients presenting with the most critical symptoms first. That means patients suffering from heart attack, stroke, etc.

In the meantime, the number of patients heading to emergency departments with psychiatric complaints has increased more than 50% in the last 10 years. Zeller says one in every eight ED visits is now somehow related to a psychiatric emergency.

Psychiatry and Emergency Medicine Working Together

We know a problem exist; now we need a solution. So what is that solution? No one has come up with anything definitive as of yet, but a good starting point has been identified: psychiatry and emergency medicine working together to treat patients in crisis.

Zeller points out that the majority of psychiatric patients can at least be stabilized in the ED. Once stabilized, many may not need to be admitted. Just like every patient complaining of chest pains will not have to be admitted for heart problems, not every psychiatric patient needs a bed.

A good way to approach this is to involve psychiatrists in training ED doctors how to handle psychiatric emergencies. Locum psychiatrists can and should be at the forefront of developing new procedures and modalities that emergency departments can adopt.

At the same time, psychiatrists could also encourage their patients to look at options other than going to the emergency room. Perhaps smartphone apps and other kinds of technologies could help those patients who do not really need to be admitted.

It is fairly routine for psychiatrists to send patients in crisis to the ED after hours. But that may not be the wisest course of action. Perhaps it is time to find a better way to address psychiatric crises after hours.