A growing trend in modern healthcare is patients using emergency departments (EDs) to access mental health treatment.

It may be that individuals with psychiatric illness fail to receive adequate care in the general medical community and turn to the ED for help, as suggested in an article published by JAMA Psychiatry.

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):372–379.

 

 

Increased behavioral health offerings

In a study published in the Journal of Clinical Psychiatry, the rate of psychiatric or substance use-related diagnosis in US EDs rose from 6.6% to 10.9% between 2007 and 2016, respectively.

Theriault KM, Rosenheck RA, Rhee TG. Increasing emergency department visits for mental health conditions in the United States. J Clin Psychiatry. 2020;81(5):20m13241.

For patients covered by Medicaid, this rate nearly doubled from 27.2% in 2007–2008 to 42.8% in 2015–2016.

 

Other research cited in the JAMA Psychiatry article demonstrated that even though the COVID-19 pandemic slowed down overall trips to the ED, visits for mental health and substance misuse did not drop to the same extent.

The Kaiser Permanente South Sacramento ED is a Level 1 trauma center that serves 127,000 patients a year.

Oakley, D. Embedding mental health care in emergency and primary medicine. Kaiser Permanente.

It facilitates care of patients with mental illness by staffing the ED with a wide variety of mental health professionals, including a behavioral health manager, licensed social workers, marriage/family therapists, and full-time psychiatrist.

 

If the patient exhibits delusions or hallucinations on initial exam, the ED psychiatry team is immediately consulted, according to the Kaiser Permanente report. A therapist and physician may also conduct separate assessments if the initial evaluation indicates that the patient’s problems are psychiatric.

This is intended to streamline the long wait for patients with psychiatric illness and follows a general trend of staffing EDs with behavioral health resources. ED mental health visits last less than 3 hours on average, and outpatient follow-up is scheduled. A benefit of this setup is the ability to quickly restart patients on psychotropic medications.

 

Addressing acute agitation

When a patient presents to the ED with acute agitation, there could be many reasons, including mental illness, substance misuse, or a combination of those factors. De-escalation is key to prevent harm, with intramuscular (IM) sedation preferred, according to an article published by EClinicalMedicine.

Chan EW, Lao KSJ, Lam L, et al. Intramuscular midazolam, olanzapine, or haloperidol for the management of acute agitation: A multi-centre, double-blind, randomised clinical trial. EClinicalMedicine. 2021;32:100751.

 

Various medications are available for the treatment of acute agitation, including benzodiazepines (eg, midazolam), first-generation antipsychotics (eg, haloperidol), and second-generation antipsychotics (eg, olanzapine).

In a randomized, double-blind trial, researchers compared 5 mg IM injections of midazolam (n = 56), olanzapine (n = 54), or haloperidol (n = 57), as reported in the EClinicalMedicine article.

The time to sedation for midazolam IM was the shortest—8.5 minutes compared with 11.5 minutes for olanzapine IM and 23 minutes for haloperidol IM. Safety profiles were comparable across the experimental groups, although one patient in the haloperidol group experienced dystonia and another experienced cardiac arrest.

 

The SBIRT approach

Screening, brief intervention, and referral to treatment (SBIRT) is a comprehensive, integrated health approach that provides early intervention and treatment services to patients with substance use disorders, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).

Screening, brief intervention, and referral to treatment (SBIRT). Substance Abuse and Mental Health Services Administration.

 

SBIRT, which can be implemented in the ED and other acute settings, entails the following:

1. Quick screening for the severity of substance abuse and appropriate level of treatment

2. Brief intervention that focuses on increasing patient insight regarding substance use, with motivation for change

3. Referral to a specialist or more comprehensive care

Currently SAMHSA is funding SBIRT programs at 17 residency programs and other medical centers across the country.

According to SAMHSA, “SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders.”

 

Sensory rooms

At M Health Fairview in Minnesota, an emergency psychiatric assessment, treatment and healing (EmPATH) approach is being pioneered, as reported by the American Hospital Association (AHA).

Zeidner L. An innovative approach to emergency mental health care. American Hospital Association.

This strategy focuses on the patient and making sure their treatment needs are met. EmPATH staff include psychiatrists, psychiatric nurses, and licensed therapists.

 

Following a brief medical evaluation, patients enter EmPATH’s calming, living room environment that offers recliners and refreshments. There, they can use tablets that play guided meditation exercises, therapeutic programs, and non-triggering entertainment choices.

During this time, the EmPATH team coordinates care and further assesses the patient, according to the AHA report. In addition to the living room, EmPATH has four sensory rooms with special lighting and sounds/music that provide a comfortable and soothing environment.

Upon discharge from EmPATH, patients are scheduled with an outpatient provider within 72 hours, when possible. An interim visit with the Transition Clinic helps avoid the reescalation of issues, AHA reported.

“The space itself is a vital part of the care,” said Richard Levine, MD, M Health Fairview’s medical director of adult behavioral outpatient service in the AHA article. “The open layout and calming atmosphere stand in contrast to hectic emergency departments.”

The design enhances our emergency mental health care and allows our care teams to do what they do best—focus on mental health and well-being.