Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
Medication isn’t the only thing that matters in mental health and substance use crisis care, but it’s a necessary component when indicated, says Dr. Charles Browning, a psychiatrist and chief medical officer at Recovery Innovations. “If you truly want a no-wrong-door approach, you need to be able to serve everyone, including people with co-occurring disorders [who may require medications],” he said, adding that without doing so, biases will persist against those most disenfranchised, leaving them without access to care. Browning and Dr. Debra A. Pinals, a psychiatrist and senior medical and forensic advisor at the National Association of State Mental Health Program Directors, along with their co-authors, have written a technical assistance collaborative paper on general medical and psychiatric approaches to crisis services care delivery as part of NASMHPD’s “Connected and Strong: Strategies for Accessible and Effective Crisis and Mental Health Services” series.
Pinals says while the forthcoming paper navigates medication recommendations for prescribers, patients and those running crisis care systems, it doesn’t do so in isolation. Instead, the authors take a holistic look at biopsychosocial approaches from a person-centered lens. “How we offer medication can’t come from a position of power or authority,” she said. “It’s really about partnership, giving information about medication — the risks and benefits — and helping people understand why medications may be part of their recovery journey.” Pinals points out that the approach shouldn’t be “take this pill and we’ll cure you” but rather, working with people across their lifespan and partnering with other systems to best meet their needs while addressing biases.
The paper includes tools the authors recommend to help crisis care organizations identify and combat biases. Among them is the Self-assessment for Modification of Anti-Racism Tool, SMART for short, by the American Association of Community Psychiatry. “It helps organizations identify whether they may have particular biases in their clinical and organizational processes,” said Pinals. Metrics measure racial diagnostic and treatment disparities, like someone’s access to specific medications and programs or whether they’re more likely to face involuntary emergency medications. The tool examines anti-racism throughout an organization in its clinical care, employment, workplace culture, community advocacy and population health outcomes. “It was created for community mental health but also fits crisis care settings,” said Browning, “providing facilities ways to analyze their data like what medications they offer and don’t offer, like Clozapine, and seclusion and restraint events.”
He says crisis care must develop national standards and evaluation processes, medical and clinical, akin to those for other emergencies, such as heart attacks and strokes. The open-source anti-racism tool is one Browning believes organizations should consider as they evaluate care disparities. “It can be used to identify racism in diagnosis,” he said, adding that a disproportionate number of Black patients are diagnosed with schizophrenia. “If that’s happening in an organization, it could be a result of implicit bias and a long-standing history of clinicians misdiagnosing and overdiagnosing schizophrenia in the Black population.” Black people are roughly 2.4 times more likely to receive a schizophrenia diagnosis than those who are white. “It’s important to shine a light on what’s happening and say, ‘Hey, what are we doing about this?”
Another tool, which happens to have the same acronym but is unrelated, is the standardized SMART Medical Clearance protocol. The protocol was developed to increase efficiency by diverting people from long wait times and unnecessary, costly medical testing in the emergency room. “Practitioners have different philosophies and there’s a long history of debates between the emergency medicine and psychiatric communities about what tests are needed,” said Pinals, noting that the protocol helps identify the level of testing a person might need to ensure timely and effective care. “To get people into psychiatric care, we often over-test and overanalyze because the psychiatric settings aren’t as equipped medically, and yet people with serious mental illness often have overlooked medical conditions — so the balance is critical.”
Medical clearance — determining if a medical issue is causing or worsening a psychiatric one or if the person is physically well enough to be placed in a behavioral health facility — is often a barrier to care. “Medical clearance and determining that a person is too acute or dangerous are the top barriers to care, disrupting crisis care and parity,” said Browning. “If you can imagine going to the emergency room and them telling you, ‘Sorry, you’re too acute’ or ‘We can’t handle the situation,’ where do you go?”
Mental health and substance use care facilities requiring medical clearance also make it less likely that police will drop a person in crisis off at a behavioral health facility instead of jail or the emergency room. In 2019, retired Phoenix police officer Nick Margiotta told CrisisTalk, “If I’m going to get medically screened out and have to put the person back in my car and drive him somewhere else, why should I even bother going there in the first place?” He believes behavioral health centers should function as if the Emergency Medical Treatment and Labor Act (EMTALA) applies to them. “… otherwise, officers will default to the hospital or jail.”
According to the Substance Abuse and Mental Health Services Administration’s National Guidelines for Behavioral Health Crisis Care, the minimum expectation for operating a crisis receiving and stabilization service is they must accept all referrals — often referred to as no-wrong door and including walk-ins and first responder drop-offs — and not require medical clearance before admitting the person. Instead, facilities should be able to assess and support patients’ medical stability while in the program and have a pathway to transfer the person to more intensive medical care if needed. Services should also be able to address both mental health and substance use issues.
That was the hurdle Margiotta ran into years ago. He was responding to a 911 call from a woman who had been drinking and said she planned to take 100 Advils. Crisis facility staff rejected the drop-off because she’d been drinking and detox facility staff rejected her because she was suicidal. “I was proud to apply my CIT training only for the person to be denied in both locations, so I didn’t do [it] again for years. All I could do was take her to the parking lot of the county hospital and say, ‘Good luck.’”
Pinals also points out that when administrators at some behavioral health facilities believe a person needs inpatient psychiatric care, they feel staff lack the expertise, equipment or infrastructure to ensure patients’ medical stability, so they add more requirements for medical clearance tests. “They won’t admit the person unless they get particular lab tests,” she said. “In the old days, that sometimes required a head CT scan, which became a source of argument as to whether someone needed that done in the emergency room.” Without standardization, there’s no list of required tests, so it falls to the whim of each facility or practitioner to determine what that looks like.
The flip side is that, in the emergency room, people with serious mental illness may not have their medical conditions addressed. “They’re not getting a physical exam that might rule out other issues,” she said, noting her experience with a medically cleared patient who never received a physical. “He was very confused, and we noted on the inpatient unit that he had a tube sticking out of his chest and learned that he received dialysis, but no emergency room exam showed that he had a serious medical condition that probably explained his confusion.” Among indicators that a thorough medical evaluation should be considered are when someone has an abnormal physical exam, presents as physically ill, has unexplained abnormal vital signs, disordered eating patterns, toxic ingestion, disorientation or fluctuating consciousness, unresolved hyper- or hypoglycemia, or is pregnant.
Browning says the SMART Medical Clearance protocol helps ensure that patients needing inpatient treatment are evaluated and that people with nonemergent physical health care problems can get treatment in a crisis receiving and stabilization center. Several states, including Wisconsin and Michigan, have adopted the protocol.
Pinals emphasizes that as communities build out their crisis systems, national standards must be put in place to prevent disparities, noting that while EMTALA was passed to eliminate some disparities of people who didn’t have the ability to pay, “We need to make sure those tenants are upheld throughout the crisis system and that we’re providing care to anyone who needs it — and good care at that.”
