FOREWORD: The Function and Characteristics of Psychiatric Emergency Services

In the United States, the psychiatric department of emergency hospitals is designed to provide professional care to those who believe that their mental condition requires immediate attention (Wellin, 1987, p. 475). Those seeking medical attention within an emergency setting are likely to believe that they are at risk of harming themselves or others. For a long time, emergency services and psychiatric treatment remained separate. Located within the general hospital, the emergency department deals with patients who are in need of immediate care due to physical injuries. On the other hand, those who are in need of assistance for mental health related issues would have to go to a psychiatric hospital, clinic, or private office. The lack of treatment for emergency situations was disadvantageous for those experiencing mental health issues, as the process for receiving treatment within these settings involves scheduling an appointment and a prolonged path of treatment. As a result of the need for immediate care in emergency situations, the rise of psychiatric care in the emergency department took place (Wellin, 1987, p. 476).

According to Edward Wellin (1987), medical anthropologist of the American Public Health Association, the origins of the psychiatric emergency hospital can be traced back to as early as the 1920s. Its evolution can be attributed to three different developmental lines: the emergency department of the general hospital, the psychiatric hospital, and the mental health movement. When there became an increased number of patients with psychological issues being brought to the emergency ward, any psychiatric residents present within the hospital would respond immediately. In addition to the general hospital, the psychiatric hospital began to develop. During the 1930s, there was the creation of “after-care emergency” (Wellin, 1987, p. 476) which provides former patients who may not have required hospitalization with additional outpatient resources and support. In addition to this, the invention of the earliest “psychiatric hotline” took place. This hotline provides people with access to psychiatric care, where clinicians propose quick responses to patients who are in need through a help center or over the phone. Not only does the hotline include over-the-phone patient evaluations, but referrals as well. Lastly, the third developmental line is the mental health movement. Referred to as the “third mental health revolution,” it resulted in the development of Psychiatric Emergency Services, or PES. This movement occurred in the 1960s, and as a result, legislation was passed defining emergency services as a required component of all community mental health centers, or CMHCs, that receive government assistance (p. 476). Subsequently, the merging of the three aforementioned developmental lines took place, which resulted in a multitude of partnerships between emergency departments, psychiatric hospitals, and community health centers across the US. According to a survey done by the American Hospital Association in 1971, psychiatric emergency services were available in 1119 general and psychiatric hospitals (p. 478). Access to these services has increased since then, and as of 2017, there were 4,612 outpatient mental health facilities, 2,538 CMHC’s, and 668 psychiatric hospitals within the United States being utilized by millions of Americans each and every day (“Mental health” 2017).

The history of mental health among those living in the United States is a prolonged and harrowing one. From as early as the Civil War, to World Wars I and II, and leading up to present times, the rise of PTSD among other mental illnesses has taken place. After these wars, many of those returning home experienced severe anxiety, insomnia, flashbacks, and nightmares. These feelings of anxiousness and restlessness can result in acts of aggression, such as acts of violence or even self-harm. Judith Weissman, a research manager at NYU Langone Medical Center, observes that the recession of 2008 was a turning point in the increase of mental illness in the US. Between the time of 1970 and 1980, there was 1 suicide every 20 minutes in the US (Kazim, 2003, p. 301). Not only have many Americans been dealing with these tumultuous mental health conditions, but the number of people suffering has only increased as time goes by. A study was published in Psychiatric Services which concludes that an estimated 3.4% of the American population suffers from a serious psychological distress (MacMillan, 2018). Also referred to as SPD, serious psychological distress is defined by freelance health and science writer Amanda MacMillan as “having any feelings of sadness, worthlessness, and restlessness that are hazardous enough to impair physical well-being” (2018). In addition to an increased prevalence of SPD, the suicide rate in the United States has risen to over 47,000 people in the year of 2017 (MacMillan, 2018). This fact means that there were approximately 2 suicides every 20 minutes in 2017, which is double the rate that it was 40 years ago. Due to the rise in people suffering from mental illnesses, there became an increased need for psychiatric institutions designed to treat those who feel as if they are endangering themselves or those around them.

Over the course of its history, the PES has combined many methods of treatment from the general hospital, the psychiatric hospital, and community health centers. While many of the original practices within the PES are still being utilized today, there has been a transformation of how psychiatrists conduct patient evaluations. Dr. Ali Kazim, a forensic psychiatry specialist at the Acute Psychiatry Service at Rhode Island Hospital, has broken down the cases that the department receives into multiple categories: suicide attempts, psychosis, and substance abuse. Furthermore, he breaks down the process clinicians use to conduct patient treatment into three parts as well: diagnosis, etiology, and treatment. Within each of these categories, there are causes and paths of treatment. For each style of patient that enters the hospital, the clinician must be able to execute the most effective method of treatment to meet the needs of their patient. Risk factors for those who are experiencing suicidal thoughts include mental illness, physical illness, and substance abuse. When it comes to these patients, safety is the top priority, and it is the job of the clinician to determine whether they are a danger to themselves or others. Therefore, the clinician will ask the patient a series of questions, such as “Are you feeling suicidal?”, or “Do you want to hurt anyone right now?” The majority of patients have suicidal intent, but the criteria extends to those with homicidal intent as well. According to Kazim (2003), “it is the legal and ethical responsibility of the clinician to make sure that the potential victim is safe” (p. 301). During an evaluation, the clinician communicates with the patient and third party sources such as relatives, friends, and out-patient sources. These out-patient sources include a therapist or a clinician from another hospital. It is the responsibility of the clinician to determine the category that the patient falls under and react accordingly. Depending on the patient’s response to the questions during the evaluation, in addition to the third-party accounts, the clinician then decides the next course of action. If the clinician deems the patient mentally fit, then they will create a plan for the patient to follow after they are discharged. If the clinician does not deem the patient fit to be discharged, then they will be admitted to the psychiatric ward. While admitted, they may be given medication in an attempt to resolve the situation. This medication includes anti-anxiety benzodiazepines, such as Ativan (Lorazepam), or anti-psychotic drugs such as Haldol (Haloperidol). Both of these drugs are administered to the patient for behavior management (Kazim, 2003, p. 302).

While psychiatrists continue to develop effective methods of treatment, the system is nowhere near perfect. A pressing issue within the emergency room is the limited space in the psychiatric department. Over the recent years, the number of psychiatric patients has increased, yet the space used to hospitalize these patients remains limited. This limited space results in clinicians delaying treatment or referring patients to another hospital. While psychiatrists are specially trained to quickly diagnose and create a path of treatment for patients, it is worth noting that they are also human beings, and sometimes errors will be made. The amount of time clinicians have to work with a patient pales in comparison to the amount of time that said patient may have been experiencing mental health issues. Thus, there are limitations to the accuracy of the diagnosis, and in the process of determining whether to discharge the patient or admit them to the psychiatric ward.

Many seeking psychiatric care within the emergency department are also unable to access it due to lack of sufficient insurance. A study published in the Psychiatric Services journal notes that the healthcare for those experiencing psychological issues has become insufficient, and as a result, many of these people are unable to receive adequate treatment for their mental health issues. The percentage of Americans unable to obtain psychiatric care or counseling is on the rise, and has grown from 9% in 2006 to 9.5% in 2014 (Macmillan, 2018). Americans who admit to suffering from an SPD have noted that it has become increasingly difficult for them to receive access to assistance. Not only are they met with delays in getting the help that they need, but they are met with difficulties paying for psychiatric medication as well. In order to accommodate the many Americans experiencing high levels of psychological stress, the United States healthcare system is in desperate need of change. However, there are many strides being made towards better practices, which is evident through the numerous research studies done within the field of psychiatry.

In order to determine if the Severe Psychiatric Illness scale is an effective means of hospitalizing the patients with the most severe cases, researchers in the Drug Abuse and Psychiatric Department of the Hospital del Mar in Barcelona, Spain conducted a study in 2006. The researchers also wanted to determine the severity of “dual diagnosis”, which refers to someone who has been diagnosed with some form of a mood disorder accompanied by substance abuse (Martin-Santos, et al., 2006, p. 152). The results of the journal conclude that a majority of those admitted to a psychiatric hospital do not have a substance use disorder, and patients with dual-diagnosis have the most severe cases (Martin-Santos, et al. 2006, p. 150). While this study did not occur in the United States, the research being conducted by these doctors does involve working towards more effective practices within the emergency room and improving patient care. These doctors are determining the efficacy of systems used within their department, as well as highlighting the issue of limited space within the psychiatric ward. This issue is not only prevalent the United States, but in emergency hospitals across the nation, thus it should be treated as such.

In 2019, the journal JAMA Psychiatry published a detailed article about a study which was conducted to determine the most common clinical symptoms of those who are likely to attempt suicide: these symptoms are called clinical predictors. These clinical predictors are looked for by psychiatrists when they conducting their evaluation of whether a patient is a danger to themselves or others. Nadine Melhem, Giovanna Porta, and Maria A. Oquendo (2019) found that many of the illnesses that patients are suffering from have been developing over the course of their life. In addition, the results show that mood disorders, history of prior suicide attempts, and child abuse are all common predictors for suicide attempts (p. 8). Those who have attempted suicide before are more likely to exhibit class 3 Depression symptoms (p. 6), which supports the hypothesis that the severity of Depression is related to the likelihood that one will commit suicide. Because of these results, researchers suggest that clinicians take more care in evaluating the severity of depression within their patients, as underestimation may result in psychiatric hospitalization.

In 2017, medical researchers Lara Chepenik and Edieal Pinker conducted a study on the impact of increased staff in the psychiatric department. In order to examine this impact, they added one more provider to the PES, who worked a four hour “half shift” between the hours of 8am and 4pm. As a result, the average length of stay for patients who were admitted decreased from 38.1 to 33.2 hours. Also, the average length of stay for patients who were discharged decreased from 13.7 hours to 8.9 hours. Most importantly, the patient volume decreased from 17 to 13 within a 24-hour period (Chepenik & Pinker, 2017). Although these results display improvements being made within the psychiatric department, the addition of providers is only effective to a certain degree. The amount of patients within the PES in a 24-hour period fails to decrease below 12, even with the addition of more than one provider. According to Chepenik and Pinker (2017), this threshold is caused by many outside factors. Not only it is difficult to contact outpatient clinicians after hours, but limited night staff prevents patient return to residential facilities. Furthermore inpatient substance treatment programs do not accept patients after hours, which means that patients who arrive intoxicated have to wait until they are sober, thus lengthening their stay in the emergency department. Regardless of the results, this study serves as significant evidence of how psychiatrists are making progress towards improving the flow of patients within the psychiatric hospital.

The psychiatric department has come a long way from its disjointed beginnings. Originating in the 1920s as a small division of psychiatrists who handled unique cases of mentally unstable patients, psychiatric emergency services have evolved into an integral aspect of hospitals across the United States. Since then, the number of mentally ill people in the US has increased exponentially, thus demonstrating a need for a more extensive and immediate form of psychiatric care. In the modern day hospital, clinicians within the psychiatric department are able to assess a myriad of complex and overwhelming situations in their line of work. However, there are many issues clinicians are affronted with that can be seen by anyone who observes while they conduct their day-to-day operations. In order to ensure access to all persons who are afflicted with mental illness, the functions of PES continue to evolve and adapt to the perpetually-changing nature of its patients, however there are still many necessary improvements that need to be made.

Following this Foreword are a series of articles that touch on the function of psychiatric emergency services in the US. Written by students at the University of North Carolina at Chapel Hill, these articles explicate the multifaceted nature of PES in their own unique way. Arendas, Barbour, Burri, and Wheless each supplement the information written in this Foreword with detailed first-hand accounts of their time spent shadowing a clinician within the accredited UNC Medical Center. Not only do they accurately depict the standard operations within the emergency department, their stories also highlight many of the current issues that are prevalent today. For instance, there are only 35 beds in the UNC psychiatric ward. As a result, patients who are in desperate need of treatment are forced to wait in anguish for long periods of time before they are admitted, or are transferred to a hospital with adequate space for them. In addition to this, they are transferred to other hospitals by a sheriff and are forced to ride in the back of a police car like criminals. The limited space and dehumanization of mentally ill patients are just some of the many pressing issues within psychiatric hospitals that are yet to be resolved.

As long as we have these problems within emergency departments, on a national and international scale, we as citizens have to continue to advocate for better methods of providing psychiatric care. In addition, healthcare providers need to take the initiative within their respective hospitals to create and implement these improved methods of care. Not only does improving patient access to PES need to continue, but providing the best care for patients paramount. Nonetheless, even in the face of adversity, psychiatrists are constantly working towards creating better methods for evaluating their patients, in addition to managing the everyday chaos that takes place within the emergency room.