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In very straightforward words that deliver a powerful call to action during Mental Health Awareness Month in May, Dr. Tariq Noohani, Regional Vice President at ApolloMD, advocates “a large, nationwide revamp and re-investment in care of psychiatric patients in the emergency department” throughout the U.S.
Why? The decades-long scaling back of psychiatric care for patients experiencing mental health emergencies and crises has overwhelmed the country’s emergency departments. This ongoing phenomenon negatively impacts emergency medicine professionals and creates ripple effects throughout the health care industry.
“The emergency department has essentially become the front door and the safety net for all of the services and facilities that used to be available to support people with psychiatric emergencies,” says Dr. Noohani, who — like all ApolloMD executives – continues to provide direct patient care in the emergency department. He is on staff at Wellstar Kennestone Regional Medical Center in Marietta, GA, one of the busiest emergency departments in the nation.
“Today, all of these patients ultimately come to the hospital, and we don’t turn anybody away in the ER. If they show up in the ER and say, ‘I need help,’ we help them.”
But it’s time, he says, for the medical system to relieve the burden on emergency departments and ease the stifling ripple effects of this ongoing influx of patients needing psychiatric care.
“Our nation’s health care system, unfortunately, is suffering,” he says without hesitation. “It’s broken. Ultimately, the safety net needs to be rewoven. What’s needed is a revamp and reinvestment nationwide into psychiatric and mental health care.”
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Negative impacts with ripple effects
From 2007 to 2022, he says, psychiatric visits to the nation’s EDs tripled because of the lack of available community mental health resources — heightened by the lingering impact of personal/social/family isolation during COVID-19, lack of insurance coverage for mental health care, and the closing of facilities/practices that provide psychiatric care. Today, patients often arrive at the emergency department with a range of psychiatric diagnoses and symptoms, says Dr. Noohani.
“They might be depressed, they may be experiencing suicidal ideation or might have attempted suicide,” he explains. “They might be psychotic or schizophrenic, or they might come in with alcohol withdrawal, substance abuse or some kind of drug/alcohol intoxication.”
Even with limited capabilities, the emergency department must accept all patients; some with severe psychiatric problems can take a week or more to stabilize before they can be released on their own, to the care of others, or to qualified facility/provider that is accepting patients, he notes.
Emergency department: The “front door” for psychiatric emergencies
According to Mental Health America, nearly 20% of American adults experienced a mental illness in 2019 and 15% of youth experienced a major depressive episode in 2021. More than half of adults with mental illness do not receive treatment and 11% do not have insurance.
The primary reason for this mental health crisis?
A 1970s-era movement to de-institutionalize psychiatric care and transfer it back to local communities was only half realized: many psychiatric hospitals/wings closed, and many mental health practitioners downsized or quit providing care — but comprehensive services did not relocate to communities as planned.
“Today, patients experiencing any kind of psychiatric emergency will present to the ER because we’re essentially the front door – the access point to health care – for everyone,” explains Dr. Noohani. “If you’re a patient, it’s not easy to pick up the phone and find an available psychiatric facility down the street. But people know that you can get into the health care system through the ER because we don’t turn anyone away.”
But most emergency departments, he points out, do not have an on-staff psychiatrist, and ED staff members, while trained in the emergent care of psychiatric patients, are not necessarily trained in the ongoing management of the full range of psychiatric illness. These patients often require transfer to an inpatient facility or timely outpatient follow-up, but unfortunately, these resources are often stretched thin and access can be delayed. Additionally, many patients are uninsured or unable to pay for care.
“The problem is that there’s such a lack of funding for all of the services that we need, and there’s no money to open more psychiatric facilities or inpatient units,” he says. “In ways, we’ve had to manage however we can in the ED for the wellbeing of all patients.”
Heightened stress in the emergency department for patients and staff
That phenomenon, he acknowledges, “has created a lot of stress for those of us working as ED physicians and providers. Yes, we’re trained to acutely manage these patients and the complications associated with their illness, but we’re not trained to manage them long-term.”
What materializes is often a Catch-22 situation for the emergency department staff. Psychiatric patients can’t be admitted to the hospital from the ED because they don’t have medical diagnoses or illness. Patients can remain in the emergency department for several days or weeks awaiting placement, “occupying a bed and staff that could be used to treat other acutely ill patients who have medical emergencies.”
EDs often end up caring for psychiatric patients – holding them and monitoring them for extended periods of time until care elsewhere becomes available. Such arrangements are stressful for emergency department staff and patients alike, especially younger patients suffering mental health/psychiatric emergencies.
“Pediatric patients have the most difficulties in the ED because it’s not a normal, natural environment,” he points out. “They tend to do the worst in the emergency department and end up staying the longest because there are even fewer community mental health resources for them.”
Extending care…but more is needed
Our teams have explored and instituted several measures to provide necessary care as cost-effectively as possible, including:
Remote 24/7 monitoring of psychiatric patients 24/7 in the emergency department, via a camera set-up and a “tele-sitter” who can immediately notify the ED professionals if a patient exhibits agitation or other symptoms that require immediate care.
Segmenting medically clear and stabilized patients who are awaiting placement together in the same region of the emergency department.
Telepsychiatry services that enable off-site psychiatrists to assess and make treatment recommendations for patients via video visits, with the ability to clear and safely send some patients home with a care plan, medications and follow-up care. “Telepsychiatry has been a big help,” says Dr. Noohani.
But more must be done to establish a nationwide safety net and care system for people experiencing mental health emergencies, he says.
“We’ve got to lobby locally, statewide and nationally for funding to help restore some of the health care system’s psychiatric inpatient capacity, including pediatric and adolescent care,” he says.
For more information on Mental Health Awareness Month and additional mental health resources, visit the following pages:
American Hospital Association
National Alliance on Mental Illness
National Institute of Mental Health
Mental Health America
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