The Dilemma of Mental Health and the Emergency Department

The emergency department is not always equipped to treat mental health issues.

Reviewed by Michelle Quirk

Key points

• Emergency departments are not always equipped to treat nebulous mental health concerns like anxiety and panic.
• Many patients who have gone to the ED for mental health problems report a lack of alleviation.
• We can learn to differentiate between an emergency and situation that does not require a crisis response.

Emergency departments (EDs) are sophisticated places that are equipped to treat a multitude of illnesses, from stitches for cuts to heart attacks, strokes, and serious diseases. But amid their countless capabilities lies a dilemma: What can an ED do for more nebulous mental health issues? And is it equipped to handle presenting problems like panic attacks or anxiety? According to an article published in Academic Emergency Medicine, the “mental health burden has often forced emergency departments to become the de facto primary and acute care provider of mental health care in the United States.” The problem is that EDs do not always know what to do with these types of admissions; further, they are often understaffed with mental health professionals such as psychiatrists and social workers and limited in the number of beds designated for mental health emergencies.

To compound the problem, many patients who have gone to the ED for mental health problems report a lack of alleviation of the presenting issue and, in some cases, traumatization as a result of their experience. In a 2016 study, patients reported a variety of negative responses to their ED visits. The findings “consist of three major themes: ‘Emergency rooms are cold and clinical’, ‘They talk to you like you're a crazy person’, and ‘You get put away against your will.’” These are oft-repeated laments of those who have turned to the ED for help with mental health issues.

But where else can we possibly go if our mental health is spiraling and we feel unmoored, frightened, or panicky? EDs, after all, are open 24/7, 365, they will admit us regardless of whether we are in or out of an insurance company’s network and have an ethical obligation to not turn us away. Doctors' offices, therapists' practices, and even urgent care centers do not boast such availability and accessibility. So, as a patient, it is difficult to know where else to turn if we are struggling.

Putting aside the inherent systemic problems with mental health care and the limitations of a hospital setting for adequately treating mental health issues, another component to explore is our human confusion at times regarding what constitutes an emergency and what does not. From a personal perspective, as a survivor of severe illness anxiety, I have visited innumerable EDs when I’ve been anxious, panicky, or experiencing a hypochondriacal response to a physical feeling of discomfort. I cannot name a single one of these visits where I experienced a true sense of relief as a result of my time in the ED. Typically, I would be there for many hours and be sent for various tests and scans, only to be assured that I was “fine.” Ironically, this did not comfort me, so severe and convincing was my anxiety that there was something wrong. In retrospect, psychotherapy and a low dose of an antidepressant helped much more than rushing to the ED did.

In her book, A Body Made of Glass: A Cultural History of Hypochondria, Carline Crampton points out that “through scans and blood tests, biopsies, and surgery, X-rays and genome analysis, the body is being rendered increasingly transparent to medical and scientific knowledge. If we can see that all is well, or if we can pinpoint the exact nature of what is wrong, perhaps our bigger fears will disappear.” Herein lies the rub: We cannot see mental health crises the way we can see tumors or blood test and lab results. Therefore, all of the incredibly advanced and sophisticated tools that an ED has at its disposal are rendered somewhat useless to a patient who reports feeling “off,” “panicked,” or “anxious.”

So, part of the solution is learning to tell the difference between an emergency situation and a situation that is uncomfortable but does not require a crisis response. In my recovery from illness anxiety, I have had to learn that not every psychical or somatic symptom signals a crisis and, therefore, warrants a trip to an ED. This is not a skill of perfection: There are still times when my anxiety brings me to a doctor’s office or urgent care setting when there is really nothing either can do to ease my discomfort. But gone are my frequent trips to the ED as I have learned to differentiate between my anxiety or panic flaring up and the need for an emergency response.

This is not to suggest that an ED is completely incapable of helping with any sort of mental health problem but, rather, that our ability to differentiate between those that require immediate care and those that do not can help us avoid an unhelpful trip to an ED. As we begin to understand the significant difference between psychological discomfort and a true psychiatric emergency, we rely less on rushing ourselves to EDs for treatment of mental health-related problems. To be more specific, let’s differentiate between common mental health issues that send patients to the ED and which can be treated adequately in a hospital setting and which cannot:

• Does not require emergency care: anxiety, panic attack, bipolar disorder, depression. (In my clinical opinion as a practicing psychotherapist, while these problems likely require care such as psychotherapy or medication, they do not constitute a medical emergency.)
• Does require emergency care: suicidality or thoughts of self-harm, hallucinations or delusions, psychotic break, uncontrollable aggressive behavior, extreme mood swings, mania, paranoia, confusion. (These issues are considered occasions to seek inpatient mental health care by the Huntsman Mental Health Institute at the University of Utah.)

While EDs are places that have the ability to treat many disparate and complex medical problems, they are not always the best places for the treatment of mental health problems. Our continued attention to the differences between discomfort and crisis can help us to find the right medical setting for the specific issue we are facing.