How Gaps In Mental Health Care Play Out In Emergency Rooms

Nearly 1 in 5 children each year suffers a psychiatric illness, according to research estimates. But a national shortage of medical specialists and inpatient facilities means that many still go untreated — despite national efforts to improve mental health care.

New research is driving home the consequences. Scientific abstracts presented Monday in Las Vegas, at the annual meeting of the American College of Emergency Physicians, offer insights into how frequently patients with mental health issues land in the emergency room — often because opportunities to intervene earlier are missed. Pediatricians and child psychiatrists say children are among the hardest hit.

The researchers analyzed data compiled by the National Hospital Ambulatory Medical Care Survey, which tracked mental health visits to hospital emergency departments between 2001 and 2011.

Compared with physically ill patients, people with mental health conditions rely more on the emergency department for treatment and are more often admitted to the hospital from the ER, the scientists found. Also, they tended to be stuck in the ER longer than people who show up in the ER with physical symptoms.

Specifically, the researchers found that about 6 percent of all the emergency department patients — of all ages — had a psychiatric condition. More than 20 percent of these psychiatric patients were admitted to the hospital, compared with just over 13 percent of the medical patients. About 11 percent of these patients with mental health problems required transfer to another facility, compared with 1.4 percent of the patients with physical ailments.

About 23 percent of mental health patients stayed in emergency care for longer than six hours, and about 1.3 percent for more than 24 hours. Only 10 percent of medical patients were under treatment in the ER for more than six hours, and just half a percent were there for more than 24 hours.

The researchers have not yet determined the distribution of ages among the patients in their study who came to the ER because of mental health symptoms. Anecdotally, though, ER patients with psychiatric problems tend to include more children and elderly patients than you'd expect to see based on the age range of the general population, says Suzanne Lippert, a clinical assistant professor in emergency medicine at Stanford University and lead author on the study.

The findings highlight what can happen when patients can't find good outpatient treatment for mental health problems, Lippert says. The evidence also underscores, she says, that when psychiatric patients arrive at the ER in a crisis, there is often no good place where they can continue treatment, once the immediate issue has been addressed.

Patients who come to the ER because of physical ailments can usually be sent home, Lippert says, "because we know they'll be evaluated by [their] doctor in one or two days." But psychiatric patients don't always have that option because of gaps in the mental health care system.

And young patients may be affected the most, says Dr. Steven Schlozman, a research psychiatrist at Harvard Medical School and associate director of the Clay Center for Young Healthy Minds at Massachusetts General Hospital. He was not affiliated with the research.

"It's a numbers game," Schlozman says. "Unless you live in a large urban area, you're very unlikely to find a child psychiatrist."

Lippert's study found that the most severely ill psychiatric patients typically spent more time in the ER. Patients with bipolar disorder, depression or psychosis and those diagnosed with multiple conditions were more likely than others to be held in the ER longer than 24 hours.

A national shortage of inpatient beds for psychiatric patients is part of the problem, Lippert says. She has seen patients have to wait longer than a week to get the inpatient treatment they need.

Such delays in cramped, overused emergency quarters hurt patients, says Dr. Thomas Chun, an associate professor of emergency medicine and pediatrics at Brown University. Doctors often agree a child needs to be transferred, he says, only to find no outside beds available.

"We are the wrong site for these patients," says Chun, who was not involved in Lippert's study. "Our crazy, chaotic environment is not a good place for them."

Meanwhile, the young patients are even less likely to get reliable care after they are discharged from the ER. Whether they need regular follow-up with a psychiatrist, or a transfer to specialized facility, the resources often aren't in place. The American Academy of Child and Adolescent Psychiatry estimates there are only 8,300 such specialists in the U.S., for more than 15 million young patients.

Dr. Lindsay Irvin, a pediatrician in San Antonio, says the dearth of psychiatrists who specialize in treating young people means many young patients simply don't get the mental health treatment they need. By the time they wind up in the ER, she says, undiagnosed depression may have progressed to suicidal intent. And after leaving the ER, many are lost to follow-up.

"They'll land in a pediatric or family practice," Irvin says, where most primary care doctors haven't been trained "to navigate the ins and outs of psychotropic meds."

Lippert and her colleagues also found that the emergency psychiatric patients were more likely to be uninsured than medical patients were. About 22 percent of mental health patients lacked coverage, versus 15 percent of patients treated for physical conditions.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.