For patients who are experiencing high anxiety, psychosis, or major depression, the emergency room — which can be loud, chaotic, and often uncontrolled — may hurt rather than help.
This environment can exacerbate symptoms, says Henry Ford Senior Staff Psychologist Dr. Jennifer Peltzer-Jones, who works in the hospital’s Department of Emergency Medicine. “It’s very overwhelming for people,” she says. “If you’re coming in and you’re depressed or anxious, ERs increase anxiety because you come there when you’re sick.”
As resources for mental health services decrease across the nation, wait times and length of stays in the emergency department have gone up.
According to a poll late last year by the American College of Emergency Physicians, more than half of doctors surveyed said the mental health systems in their communities have “gotten worse,” with the emergency department becoming “the dumping ground for these vulnerable patients who have been abandoned by every other part of the health care system,” Dr. Rebecca Parker, president of the American College of Emergency Physicians, said in a press release. Only 17 percent of doctors reported having a psychiatrist on call to respond to psychiatric emergencies in the ED.
An already scary environment can become even scarier for those who work up the courage to come in for treatment. Unlike many physical illnesses, mental illnesses can be difficult to pinpoint. Therefore, if a person who is quiet and depressed comes to the ER for help, it may not be obvious to treating physicians what they’re actually there for.
“There’s a group of patients who come to the ER who are not coming right out and saying [they have mental-health concerns]; they’re coming in with stomach problems or migraines,” says Peltzer-Jones, who oversees the psychiatric patient flow in the ER at Henry Ford and is one of the primary clinicians who conducts emergency evaluations. “They don’t always share what’s going on and they leave without resources because the ER overwhelmed them and they believed they were going to be admitted.”
Commitment, which is clinical or court-ordered treatment in a psychiatric hospital or outpatient program, is a misconception among some seeking mental health treatment, but the prevalence is exaggerated. To qualify for commitment, a person must reasonably be considered a danger to themselves or others based on past supportive acts or threats; unable to take care of basic physical needs due to mental illness; or unable to understand a need for help and in danger of harming themselves or others because of judgment that is so impaired by mental illness. People who have alcohol or drug dependency, a primary diagnosis of epilepsy, or mental processes weakened by dementia do not qualify for commitment if they do not meet the prior criteria.
For the general public, the guidelines can blur: People fear being taken away from their families, jobs, and homes. However, commitment is far from standard protocol.
“People have these ideas that they’re going to go to One Flew Over the Cuckoo’s Nest and they become scared,” Peltzer-Jones says. “They think, ‘If I’m going to tell somebody, they’re going to lock me away.’ ” (The 1975 film, adapted from the novel of the same name, follows the story of a criminal placed in a psychiatric unit despite not having mental illness.) “And we’re not going to lock you away. We don’t want to.”
Generally, about 2-3 percent of patients seeking care in Henry Ford’s ED are seen by the mental health team; less than half of patients with a mental health emergency are referred for inpatient psychiatric care. Laura Wotruba, director of public affairs for the Michigan Health and Hospital Association, says only 4 percent of all inpatient admissions across the state last year were for a primary mental health diagnosis; 31 percent had a primary or a secondary diagnosis. Like coming in with physical chest pains, those with mental health emergencies don’t always fit the criteria for admission.
“There’s risk assessment, there’s access to care, there’s level of severity of the illness, other co-occurring illnesses,” says Peltzer-Jones. “In evaluating psychiatric crises, we do it in much the same way.”
A Need for Support
In terms of risk assessment, physicians often evaluate a patient’s level of community support: Do they have a place to stay, do they have family to engage in a treatment plan, are there people who are aware of what’s going on?
The most severe mental health crises are suicidal thoughts, plans, and attempts, so developing and maintaining social connections for patients is a top priority. According to the Suicide Prevention Resource Center, one in 10 suicides is completed by people seen in an ER within two months of dying; many were never assessed for suicide risk. Ten percent of all ER patients are thinking about suicide; most don’t say so.
Thomas Joiner, one of the leading experts of suicide in America, developed the interpersonal-psychological theory of suicidal behavior in 2005. According to the theory, those who feel a lack of connectedness or feel like a burden to their families are at the highest risk, because they become less afraid of dying as a result. Other risk factors for suicide are psychosis, high anxiety, depression, and alcohol abuse, along with social issues like work problems, marital problems, loss of job, or loss of relationships.
For people in such crises, an alternative level of care is a partial hospital program, which is sometimes called a day program or intensive outpatient program. These programs include one-on-one interactions, group therapy, and the same evaluation one would receive in an inpatient psychiatric unit, except with the option of going home at the end of each day.
“Oftentimes partial hospitalization is not thought about,” Peltzer-Jones says. “When patients are discharged from inpatient psychiatric care, stepping down to a partial program is an important piece in the continuum. If your level of crisis is such that you need that extra coping, or that extra increased daily support, partial hospital programs are highly beneficial.”
There are other types of intensive outpatient programs. Henry Ford has an evening program at its Maplegrove Center, which is an addiction treatment facility for adults and youth. Such programs are best for those who don’t want treatment to interfere with their jobs.
“Interventions for patients need to be balanced,” Peltzer-Jones says. “By missing work, you may further exacerbate your finances or increase your level of stress.”
Those with mental health emergencies may also be able to get help through an employee assistance program if one is in place. But Peltzer-Jones says people are often unaware these exist.
“If you’re running into some issues with budgeting and management that is going to negatively affect your work, there are free benefits,” she adds. “Oftentimes the program can help the person in distress have the support so they don’t lose their job; the whole goal is to not lose your job.”
It’s all part of crisis stabilization, a vital intervention in recovery that teaches people the coping skills they need to remain stable in their communities. It’s a bridge to treatment. “One of the cognitive distortions of crises is all-or-nothing thinking: People have a difficult time in creating alternative plans because they’re in this spectrum where everything’s falling apart and there’s nothing they can do,” Peltzer-Jones says.
A Top Issue in Behavioral Health
One of the biggest hindrances in seeking mental health care pertains to access, whether it’s an actual lack or a perceived one.
For those having a nonmedical mental health emergency, area mental health authorities such as Detroit Wayne Mental Health Authority, Oakland County Community Mental Health Authority, and Macomb County Community Mental Health can help save patients a trip to the ER.
In the past few years, the mental health authorities have combined their efforts to strengthen treatment by reorganizing and redeveloping crisis services. They offer personalized and consistent interventions that alleviate the pressure and stress of the ER with easier ways to reach out, such as crisis hotlines and text lines. They also deploy mobile crisis teams that will come directly to patients and set up a plan in their homes or at the ER to get them back out into the community, with services available for up to 30 days.
DWMHA offers a program called COPE: Community Outreach for Psychiatric Emergencies. Within the hospital system is a crisis known as “emergency department boarding of psychiatric patients,” where patients wait upwards of days for a bed; Dr. Carmen McIntyre, chief medical officer at DWMHA, says it is one of the biggest issues in behavioral health. Because of deinstitutionalization — pushing people out of state institutions — many psychiatric hospitals are old and not up-to-date, which results in a lack of staffing, in turn creating a lack of available beds and a backup in ERs.
COPE was created to assist people in the community with psychiatric needs. A COPE team will come out to assess the situation or provide a screening when called. Collectively, they come up with a plan for care. This new one-on-one interaction is highly beneficial for patients, Peltzer-Jones says.
“These mobile teams will come out to the ER within a certain amount of time so patients aren’t suffering from long lengths of stay,” she says. “Patients can call and access this program on their own 24 hours a day to connect with crisis services.”
McIntyre says one contributor to the ED boarding crisis was the lack of a system for treating with alternative resources. “Because it’s not their specialty, ED physicians would end up ordering hospitalization on an involuntary certification,” she says. In the case of high-risk physical emergencies, such as stroke and heart attack, physicians worked alongside specialists to develop safe treatment algorithms; the mental health field is now recognizing the same need to guide ED physicians in safe, alternative treatments for psychiatric emergencies. By sending a behavioral health professional to work with ER patients in crises, the state found that they were almost always able to get rid of the involuntary hospitalization process.
OCCMHA Chief Network Officer Matt Owens says they were able to create successful plans for people to return to the community 80 percent of the time through OACIS (Oakland Assessment and Crisis Intervention Services). The OCCMHA operates the Resource and Crisis Center (RCC); Common Ground manages crisis programs in the building via contracts through OCCMHA, including OACIS, Crisis Residential Unit (a voluntary, diversionary option from inpatient hospitalization), and the 24-hour Resource and Crisis Helpline. Approximately 6,400 people receive crisis intervention services through OACIS each year.
OCCMHA serves 25,000 county residents, including individuals with intellectual/developmental disabilities, adults with mental illness, children with serious emotional disturbance, and persons with substance use disorders; most of these individuals have Medicaid.
“ED boarding is an issue,” Owens says. “What we’re doing to combat that is very helpful and the things we’re doing on a tri-county basis are also helpful.”
Meanwhile at MCCMH, patients can seek help at the UBHC, an urgent behavioral health care center. Opened in October 2016, the center has seen approximately 1,400 individuals since, 30 percent of which were children; less than 10 percent of those children had to be admitted for inpatient care.
“We were able to de-escalate the situation or find alternative treatments for them,” says Jim Losey, MCCMH deputy director. For adults, 20 percent seen needed inpatient care. The center provides support up to 23 hours a day and has eight adult beds and three children beds.
MCCMH also offers MERG, the Macomb Emergency Response Group. This trained volunteer group provides debriefings for community members who have witnessed or been part of a traumatic event and works closely with schools and public safety.
“We are looking at double the number of consumers coming to see us in January than we did in December,” Losey says. “Word is getting out, but there’s work to be done in making sure the community is aware that this really is the first place to stop to get crisis services.”
“It takes a lot to walk through the door of an ER and admit that you’re feeling depressed and suicidal,” Peltzer-Jones says. “It takes a lot to admit you’re starting to have thoughts that are scary. If we gave people more resources where they didn’t have to get the courage to come to the ER … these are things to stop and think about.”
Where to Turn to for Help
If you or someone you know is having suicidal thoughts, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). You can also text 741741 to be connected with a counselor to talk about anything that’s on your mind.
Detroit Wayne Mental Health Authority can be reached at 313-833-2500. To reach their 24-hour crisis helpline, call 1-800-241-4949.
OCCMHA’s current network of service providers include: Common Ground, Community Housing Network, Community Living Services, Community Network Services, Easter Seals Michigan, Macomb-Oakland Regional Center, Oakland Family Services Inc., and Training and Treatment Innovations. A complete list of substance use service providers is available on OCCMHA’s website. For more information about OCCMHA, call 800-341-2003 or visit occmha.org. Reach the 24-hour crisis helpline at 800-231-1127.
Macomb County Community Mental Health’s Urgent Behavioral Health Center can be reached at 586-466-6222. To reach their 24-hour crisis helpline, call 586-307-9100.