Emergency departments pushed to the brink again


Emergency Department (ED) visits for mental health conditions have spiked by double digits across the U.S., especially for children. From Boston to Los Angeles, and here on Martha’s Vineyard, clinical teams are overwhelmed trying to help patients in a system not designed or resourced to manage it.

During the pandemic, the surge of pediatric mental health patients led medical groups including the U.S. Surgeon General to declare the crisis a national emergency. Despite this emergency declaration, reality on the ground saw mental health beds and resources across the nation being repurposed or eliminated to make room for critically ill COVID patients.

Working two years straight in warzone-like conditions, frontline medical staff are also in need of mental health support. Data shows 76 percent of healthcare workers report exhaustion and burnout. More alarming, half are seriously questioning whether they should remain in the field.

In recent weeks, numerous states have held emergency meetings to address the lack of staff, beds, and resources to manage the flood of patients. New York State eliminated 400 inpatient psychiatric beds during COVID, and today has only 274 psychiatric beds statewide for pediatric patients (down from 554 in 2012).

The worst day of a patient’s life often gets worse.

The hospital emergency department is the frontline for mental health emergencies, yet there is mounting evidence it should not be. Crowding, limited resources, clinician time constraints, lack of beds, and an incongruence of care sets the ED as a site for subpar mental healthcare. Unfortunately for millions of patients, it’s the only place to receive care, as one-third of Americans live in areas lacking mental health professionals. 

As they are trained and wired, emergency leaders continue to rise and manage multiple pandemics simultaneously, but can only resuscitate a frail system back to life so many times. Researchers recently had to publish guidance around the involvement of law enforcement (including the use of restraints) when transferring students in mental health crises to the ED.

For many, a medical transfer (squad car, ambulance), location (crowded waiting room), and boarding (waiting days for a psych bed) is a poor use of scarce resources, magnifying the stigma and stress for patients navigating a broken system during the most stressful time of their lives.

To be clear, the ED as a point of entry for mental health emergencies will always play a critical role in mental health care. In fact, one in eight ED visits in the U.S. is related to a mental disorder or substance use. Emergency behavioral health services for the acutely ill are a lifesaving resource that must be appropriately funded and designed. However, many hospitals will never attain that level of specialization, so support must include infrastructure outside the ED, including community clinics, mobile crisis assets, and homecare.

Health systems desperately need resources and leadership to partner with community-based organizations before a crisis brings the patient to the ED. This crisis has encouraged innovative new models, with one showing 80 percent of patients in behavioral health crisis can be stabilized and returned home or to outpatient care within 24 hours. There are other successful examples, like Intercept here in Massachusetts, which provides immediate treatment for children in their home. Here on the Island, there is pioneering work underway addressing substance use disorders by identifying at-risk individuals and then activating a HUB of community resources to provide care before a crisis. Some states, like Arizona, launched a 988 response program (emergency 911 line for mental health crisis), but many states desiring a similar system will grapple with funding for infrastructure and staffing.

There is positive news, and indication of relief, on the horizon. Congress is set to vote on an $8 billion package with bipartisan support that would allocate funds to national mental health initiatives. States would receive funding for certified community behavioral clinics that provide mental health and substance abuse care. In addition, the Centers for Medicare and Medicaid Services (CMS) recently extended telehealth services to add a patient’s home as an acceptable site for treatment of a mental health disorder. The Department of Health and Human Services (HHS) is looking to expand access to mobile crisis services in high-need communities. 

Without congressional support and funding at the national and state level, our system will continue to fail patients, providers, and communities. We are done overrunning emergency departments, and accelerating the exodus of healthcare professionals, unless we want more homelessness, incarceration, and national hurt. Mental health affects all of us, and this proposed funding is especially critical, since those healing the nation are now also hurting.


Meghan FitzGerald is an adjunct associate professor with the Columbia University Mailman School of Public Health, private equity investor, emergency department volunteer, and author of “Ascending Davos: A Career Journey from the Emergency Room to the Board Room.” She lives in Aquinnah, and can be found on twitter @ MMAmeg.