More than four decades ago, an article appeared in the American Journal of Psychiatry defining the subspecialty of emergency psychiatry (EP). Since those early days, despite some research and consolidation into a new association complementing emergency medicine (EM), the impact on meaningful access to, integration with, and quality of care for psychiatric emergencies has been inconsequential.
In point of fact, one of the factors impeding progress in EP has been, in my opinion, the lack of momentum from the very entity professing support of the critically mentally ill.
Although the American Board of Psychiatry and Neurology offers 15 psychiatric subspecialty certifications, EP is not among those accredited core areas approved by the Accreditation Council on Graduate Medical Education (ACGME). Furthermore, the current ACGME EM residency program requirements do not specify that programs ensure residents have ample experiences treating psychiatric patients. Yet, the majority of EM residents believe, as do their psychiatric counterparts, that their program should offer more education on managing psychiatric emergencies.
Based on these unsettling facts, it appears that EM, as well as psychiatric residents, are expected, in the face of adverse clinical and supervisory experiences, to develop competent skills in treating psycho-behavioral conditions through on‐the‐job training in the ED. Good luck.
Over the last 4 years, I have written about behavioral health emergencies including the simultaneous impacts of unusual presentations, inadequate assessments, stale methodologies, violence against staff, pandemic lockdowns, anaphylactic suicide, and an equation for suicidal lethality. I have introduced an American College of Emergency Medicine (ACEP)-specific and Centers for Medicare & Medicaid Services (CMS) supported algorithm for consistent improvements in risk medical decision-making with revenue cycle management benefits. I have emphasized that the number of behavioral emergency chief complaints, now estimated to be one in every seven patients of approximately 140 million annual U.S. ED admissions, demands competent triage, admirably fast stabilization, and staff safety. These collective educational and protective factors against increasing patient and ED violence, boarding, and burnout cannot be understated.
Clearly, the pathway to positive change in EP is a noble goal from afar, but oh what a mess we've made. The need to address the current U.S. mental health crisis and to climb to even higher levels of workforce supply and proficiency is considerable. But is it too little too late? In other words, is the opportunity for significant change in youth and adult mental healthcare going, going, almost gone?
It is now sadly possible to paraphrase the inimitable Yogi Berra's baseball imagery from "It is getting late early" to "It is now very late early."
The Demand Crisis
- In 2021, The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children's Hospital Association declared a state of emergency in child and youth mental health.
- Despite efforts to reduce suicide risk in young adults in the U.S., rates of suicidal ideation and suicide attempts in people under the age of 22 are increasing.
- Recent analysis reveals that only 37% of all youth presenting to an ED with a suicide attempt were seen by a mental health professional. Less than a third had an outpatient mental health visit within 7 days of ED discharge; a little more than 55% had a follow-up within 30 days.
- The CDC reports substantial increases in suicidal thoughts and substance abuse throughout the country. In 2020, an estimated 12.2 million adults seriously thought about suicide, 3.2 million made a plan, and 1.2 million attempted suicides.
- The number of suicides was higher in 9 months during 2021 compared to 2020. The largest increase in the rate of suicide occurred among males ages 15-24 -- an 8% increase. Suicide rates also increased for males ages 25-34, 35-44, and 65-74.
Dwindling Supply Coupled With Inadequate Proficiency
- Within a few years, there is an expected psychiatric workforce shortage of between 14,000 to 31,000 psychiatrists (depending on population ratios used).
- Of over 3,100 U.S. counties, 50% do not have a psychiatrist and 77% report a severe shortage. Over 60% of rural Americans live in a designated mental health provider shortage area.
- With only 8,300 trained U.S. child and adolescent psychiatrists, just about 20% of children with mental, emotional, or behavioral disorders are able to receive care from a specialized mental provider.
- Only about 25% of emergency medicine residencies provide formal instruction in acute psychiatric management.
- Although research investigating the current state of EP training during general residency is limited, at best, minimal formal EP education is provided. Currently only five EP -- not ACGME accredited fellowship programs -- exist generating few graduates annually.
Suggestions
It is essential to establish psychiatric emergencies as the legal and medical equivalent of medical emergencies, advocate for ACGME accreditation of current and new EP fellowships, and promote improvements in resident recruitment and training. Clearly, readily available EP expertise represents both a need for the community and advancing the field, but it remains haphazard. Beyond these steps, how do we advance prompt practical ED solutions to meet some of the crisis demands outlined above?
Past recommendations have been plentiful but far less than promised. The following are two innovative paths with direct, measurable, judicious impacts on demand and proficiency.
First, community EDs, with EP input, must immediately integrate risk triage training with local schools, including universities. Combined workshops could address the current ED psychiatry crisis and the overwhelmed mental health system thus improving the balance of patient and hospital consequences to benefits. Increasing awareness of skills required and challenges experienced in respective settings could encourage crosstalk preventative strategies, innovative diagnostic adeptness, and personalized care with timely follow-up and safety benefits.
Second, CMS has, at long last, incentivized behavioral healthcare that focuses on high-risk populations. Implementation of research supported and EP practiced AI ICD-10/CPT coding provides improved provider and hospital revenue benefit. Specifically, ACEP triage guidelines will be available where and when needed. Medical decision-making using social determinants of health on risk underscores non-stigmatizing benefits including staff satisfaction, ED flow efficiencies, and patient safety.
In summary, over 30% of persons who die by suicide are treated in an ED, outpatient specialty, or primary care 7 days prior to death. Undoubtedly, it is only access to competent EP care -- not ED or community care alone -- that holds the potential for transformative, realistic reduction in suicide rates beyond annual Zero Suicide and CDC aspirational projections. These patients deserve definitive care. EP physicians, fellows, and non-EP clinicians deserve excellent support.
Russell Copelan, MD (Ret.), lives in Pensacola, Florida. He graduated from Stanford University and UCLA Medical School. He trained in neurosurgery and completed residency and fellowship in emergency department psychiatry at UC, Irvine and University of Colorado, Denver. He is a reviewer for Academic Psychiatry and founder of eMed Logic, a non-profit originator and distributor of violence assessments. Copelan is also a presenter for the National Association of School Psychologists (NASP) Speaker's Bureau, and a consultant to the American Association of Suicidology.