A study published on JAMA at the end of 2019 revealed that people who went to the emergency department (also known as the emergency room) with non-fatal deliberate self-harm or suicidal ideation were at high risk of suicide within the first year after discharge. Researchers Sidra Goldman-Mellor, Ph.D., Mark Olfson, M.D., MPH, Cristina Lidon-Moyano, Ph.D., and their colleagues looked at patient record and mortality data for 648,649 people who visited an emergency department (ED) in California between 2009 and 2011. What they found is that suicide mortality was nearly 57 times higher among patients with deliberate self-harm—with or without suicidal ideation and 31.4 times higher among those with suicidal ideation but not deliberate self-harm.
Peeling back what outcomes could have looked like otherwise for these patients can appear subjective, and to a certain degree, that’s true. Some experts would argue that these individuals represent the most acute cases, and thereby, the ED is where they should have been. The outcomes, they would say, are simply what would be expected among what they believe to be a highly acute population. Yet, it isn’t that simple. Leading expert on suicide, David A. Jobes, PH.D., ABPP, a psychology professor and the director of the Suicide Prevention Laboratory at The Catholic University of America in Washington, D.C., says the ED has become the default crisis service provider for people experiencing a range of mental health needs, including those who ran out of or lost medication and don’t have anywhere else to turn. The problem, says Dr. Jobes, who developed the Collaborative Assessment and Management of Suicidality (CAMS), a suicide-focused psychological treatment that is designed to change people’s suicidal thinking and behavior, is that “one size doesn’t fit all.” Meaning, the healthcare field isn’t matching appropriate treatments to the range of crises people are experiencing. He says the reason why is in large part because of gaps in crisis services—like 24-hour outpatient psychiatric urgent care facilities—but also because of provider anxiety. “Fearing malpractice litigation, clinicians are practicing defensively, which means they are sending too many people to the ED who could function quite well with appropriate outpatient treatment, crisis intervention, or by reaching out for support from a crisis center text line or hotline.”
The idea that a person is getting what may be perceived as more care might seem like a good thing. It’s not. Emergency departments are filled with hard-working, well-intentioned people who dedicate their lives to saving lives, but most know little about psychiatric health. Sandra Schneider, M.D., FACEP, a past President of the American College of Emergency Physicians, told us in May that current day emergency mental health is reminiscent of the 1950s ED. She called it “a throwback in dire need of an upgrade.”
Throughout the United States, people in mental health crises quickly discover that going to the ED for treatment is a waiting game: they wait for urgent psychiatric care and then wait again for continued care. Last year, the Voice of San Diego reported that people ended up in the ED for long hours, even days, awaiting treatment. A snapshot of what happened next, looking at patients between July 2018 and May 2019, revealed collective wait times of over 13,200 days in inpatient hospitalization among adults with Medi-Cal for lower-level mental health care after doctors determined they were stabilized and could be discharged.
The trend of overflow from people in the ED waiting a long time for treatment, commonly known in the mental health field as psychiatric boarding, drew nationwide attention in a landmark case in Washington State. Ten psychiatric patients filed suit against the state in 2013 and won, with the Washington Supreme Court siding with the patients and banning psychiatric boarding. The court ruled that state law “does not authorize psychiatric boarding as a method to avoid overcrowding certified evaluation and treatment facilities.” The Seattle Times reported that people had been detained for days, and sometimes months, while bound to hospital beds parked in ED hallways while awaiting evaluation and admittance to treatment facilities. Sometimes they were given medication. Other times they were not.
The number of ED visits for mental health crisis has been on the rise, growing by 55.5% between 2006 and 2013 for visits involving depression, anxiety, or stress reactions, 52% for psychosis or bipolar disorders, and 37% for substance use disorders. This is not to say suicidal ideation should be ignored, quite the contrary. Dr. Jobes says it warrants an immediate and appropriate-level clinical response, but what’s happening is that clinicians aren’t starting with the least restrictive approach, but, instead, they overreach. “It’s like cracking someone’s chest open to do exploratory surgery for mere chest pains when a much less invasive clinical assessment would be appropriate and absolutely in the patient’s best interest.”
Dr. Schneider says the ED experience often triggers numerous challenges for patients, including the corresponding trauma of institutionalization, stigma, and potentially, an adverse impact on employment, finances, and personal life. Defaulting necessarily to the ED also removes people from their day-to-day lives when, in most cases, that doesn’t have to happen, says Dr. Jobes, and “we are now learning that over-use of inappropriate ED care has a cost.”
Fortunately, noteworthy shifts are happening. Modern Healthcare reported in early January that all 6,146 hospitals in the United States experienced a decline in outpatient visits in 2018. The decrease was specific to ED visits. Aaron Wesolowski, American Hospital Association vice president for policy research, analytics, and strategy, told the publication that patients who once went to the ED are now going elsewhere, such as urgent care clinics. Hospitals have not seen a year-to-year decline like this since 1983. That said, hospitals’ outpatient and inpatient net revenue rose 4.5% and 2.1%, respectively. Chad Mulvany, director of healthcare finance policy, perspectives and analysis at Healthcare Financial Management Association, told Modern Healthcare that the decrease in ED visits but increase in outpatient and inpatient revenue might indicate that people are comfortable going elsewhere when they need less intensity of care “…and if it becomes more complex than that, they’re going to the hospital…” It’s unclear yet what the implications are for mental health.