Psychiatric and Substance Abuse Crisis in Emergency Settings

Let me start by saying this—mental health care and substance abuse care in this country needs a MAJOR overhaul. Inpatient psychiatric beds are extremely limited, outpatient and aftercare programs are hard to get into, and funding just keeps getting slashed and beds eliminated.

I could go on and on and on, but I really want to talk about acute crisis and why emergencies departments struggle to meet the needs of patients suffering acute psychiatric and substance abuse issues.

They often go hand in hand—people self medicate because their brain is on fire and they don’t know how to make it stop. 

So, you have a lot of “dual diagnosis”, or depression with a side of alcoholism. Both problems require treatment, are complex and difficult to treat in an emergency setting, and often require lifelong care and attention. 

The following is based on multiple experiences at multiple facilities—over fifteen years. Not one hospital. Not one county, or city, or any of that.

 So, a patient who comes in either makes a suicide attempt, or verbalized suicidal ideation to someone, and is brought into an emergency department, either by family, friends, ambulance, or police.

Good! They’re seeking help! Or being forced into it. Either way this is a step in the right direction. 

Problem #1. Emergency Departments are basically a war zone. Someone’s always screaming, alarms are always blaring, all the lights are always on, and it’s CROWDED. So you have someone suffering a major crisis, overwhelmed, maybe angry, maybe exhausted, and you’re throwing them into a place I’ve heard described as the seventh circle of hell more than once. 

Sometimes there’s a private room. Sometimes there’s not. Now, here we get into some really problematic shit. 

The patient is at risk of harming themselves. Or others. So, they must remove their clothing and place on safe clothing provided by the facility. They can’t have backpacks, sharp items, big items, metal, forks, anything to that might hurt ANYONE. So here they are, at their lowest point, and now they’ve got to wear paper or cotton scrubs, give up their stuff, AND have a sitter—someone who is required to keep the patient in eyesight at all times. Sometimes, if the patient is considered extremely high risk, in arms reach at all times.

I don’t like this. I imagine myself as the patient and imagine I would feel embarrassed, ashamed, judged, and angry.

On the other hand, people who truly wish to harm themselves will do so. In any form they can. I have seen situations where patients attempted to harm themselves in ways I never thought possible, and nearly be successful. 

The point is, we have to keep them alive and safe, and that comes at a cost. It’s unfortunate, but this is an area where you can’t negotiate. Safety first, for both the patient and the staff. 

Now, the patient also has to be medically cleared prior to psychiatric screening. Blood and urine and vital signs. These take one to two hours to result, and then we request a psychiatric screening to evaluate for inpatient psychiatric placement or safety planning—which means the patient is given outpatient resources and a safety plan which involves family or friends and follow up. 

Ok, screening time, right?

No. It depends on how long the list is to be screened. Mental health professionals are just as overwhelmed as emergency departments. It can be one, two, four, six hours until the screen is performed. 

So now we’re at 2-8 hours in the ER. 

The nurse caring for the psychiatric patient also has other patients. Kind of hard to give therapeutic communication when the guy next door is having a heart attack. The doctor is intubating someone. The patient is asking the sitter how much longer? How much longer?

Ok, the screener finally comes, either in person, or via telemedicine. The patient is evaluated. Permission is asked to contact family or friends to form an aftercare plan. 

Ok, the screen is done.

 Very few patients in the emergency department who made an attempt at suicide are going to be safety planned. In 2020, over 48,000 people in the United States committed suicide. It was the second leading cause of death in ages 10-34 and the fourth for ages 35-54. Suicide is a very serious matter and it cannot be taken lightly or dismissed attention seeking behavior. If a patient is found in need of inpatient psychiatric care, they are either voluntary or involuntary. 

Now, if a patient is voluntary AND has good insurance, beds are often found within 24 hours. 

A lot of patients with psychiatric diagnoses don’t have great insurance. 

Voluntary and crappy insurance or Medicaid or a states version of it? Only a few facilities will accept. Guess what. They have waiting lists. So, hopefully with 3-4 days. In the meantime, guess where the patient stays? 

In the land of chaos. 

If a patient states they will not go willingly to an inpatient facility, things get worse. The patient must be rescreened and deemed to be unable to have capacity to make that decision. They are placed on a hold and then a waiting list. 

The number of facilities that will accept involuntary committed is very few. They have a long waiting list. You can be looking as long as a week or two for placement. 

Guess where that patient will wait for a bed. 

You got it. 

It’s FUCKING ATROCIOUS. A week or two, in a small windowless room, with someone watching your every move. Eating hospital food. Limited TV channels. No sun. No therapy. Maybe medications. 

Now sometimes we get lucky. Sometimes those meds help A LOT and we can rescreen the patient and get them a safety plan outpatient. 

Sometimes we can’t. 

We do everything in our very limited power to help these patients. Showers. Walks. But goddamn, we are overstretched as it is. Me? I’d go ballistic trapped in such a situation. 

So what do we do? 

We need emergency areas specifically dedicated to psychiatric crisis. Areas that are staffed by psychiatrists and psychiatric nurses and mental health technicians who are TRAINED specifically to meet their needs. These areas need to be placed AWAY from the hustle and bustle of the main emergency departments. There is too much stimulation in the ER. Sometimes I, a person who thrives in chaos and mess, gets so overstimulated I’m about five seconds away from screaming EVERYONE JUST SHUT THE FUCK UP FOR FIVE MINUTES. 

So basically, an inpatient psych area but for those needing screening. 

But there’s no MONEY for it. There isn’t enough funding , there aren’t enough areas, or staff. 

And here’s the deal, and I’m going to be really honest. I wish I was better at psychiatric nursing. But it’s extremely complex, just like trauma, and cardiology, and neurology. Just like those specialties, I have to focus in on the emergency aspect of it—I’m a Jack-of-all-trades. I have so much to stay abreast of I cannot become a psychiatric expert, just like I can’t be an operating room nurse, or a cath lab nurse. These are very specialized fields—paying attention to one field means if I neglect another, someone might die. 

This is why STEMI patients go to cath lab. Appendectomies to the OR. But the psych patients have nowhere to go. So where are their specialized nurses?

*crickets*

Again, this is across the United States. 

I did work at a hospital that had a small psych area at the back of the ER. It was always full, and spilled over into the main department. There were no day rooms, therapy—it was a holding area. The only benefit was it had a shared shower and was away from the noise. 

It was staffed by ER nurses, who are already struggling with a pretty significant amount of burnout and who all feel pretty dismal about the limitations they face on psychiatric care. 

So, fixing it in an emergency setting-because again, I could scream for hours about the lack of aftercare, funding, all those things.

Outpatient crisis areas, staffed by specialists. 

That’s what can fix it. More available beds. 

Ok, now for substance abuse. 

The problem with substance abuse is a lot of people who abuse substances that end of in the ER are at the tail end of their addiction. It’s a bad place to be. The problem with alcohol and drugs is that it takes everything by that stage. Jobs. Family. Friends. Trying to get sober when you feel like there’s nothing worth getting sober for is a real bitch. People at this stage of addiction are in a tremendous amount of pain. They drink/use to get rid of it, which creates more pain, creating a cycle that doesn’t end. Until it does. 

So, the problem with substance abuse is that it’s difficult to get people into inpatient programs, which many of the people coming into the ED truly need. Especially because by the time you NEED an inpatient substance abuse stay, you don’t have the $$$ or insurance for it. There are some super nice inpatient places but whoooo boy pony up those dollars. Now, the federally funded programs exist, but the wait list is long. Just like for psych facilities. So now we have a real problem. We can medically detox and give prescriptions for withdrawal, but we can’t keep them in the ER or hospital until a bed becomes available. Even if we could, it would bankrupt them for the rest of their life. 

Just like with psych, we need more money and more beds. 

Also, if someone is choosing the path of addiction, but they’re not suicidal, you can’t deem them a danger to themselves. Drinking yourself to death is a form of suicide, but it doesn’t count for immediate danger. Like one doctor said, people are allowed to make their own choices, even if they’re bad ones. Free will and all that. 

What would be awesome is intervention teams. Alcoholics/addicts in recovery along with a clinician to set up outpatient care and stuff like that. Obviously the AA and NA programs have established themselves as having success, but there also sober living houses, outpatient therapy, and a lot of times substance abuse issues mask other problems, like depression, or ADHD, or bipolar disorders. 

They could be on call, come in and visit with patients willing to speak with prior to discharge, and start the beginning of a support network. 

Guess what all this will take? 

A major overhaul of the system. Money. Changing the way and the settings in which we treat patients in crisis. Ensuring transition from an emergency standpoint to continued care, inpatient or not, is paved with resources and support. 

If you’ve hung in there with me, thank you for listening and please know, we want to help—we want to be better. Like with many of the other things I rant about, we lack the tools and resources. 

— the Midwestern One