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A mental health crisis in emergency care: emergency departments lack adequate in-house and community resources to care for suicidal patients.

The lack of adequate outpatient psychiatric services, especially for uninsured and underinsured patients, has rendered emergency departments (EDs) one of the few remaining options for psychiatric patients. A study published in 2004 provided statistical evidence of this dynamic, showing that psychiatric-related ED visits (those reflecting any of three common psychiatric ICD-9 codes for a suicide attempt) increased 15% nationwide from 3.7 million in 1992 to 4.3 million in 2000, representing 5.4% of all ED visits. (1)

In a national survey of 340 emergency physicians conducted by the American College of Emergency Physicians and mental health organizations, 67% of respondents said mental health services had declined in their communities during the previous year, and 60% reported increased pressure on the front line (i.e., EDs), particularly because psychiatric patients consume provider attention, increase patient boarding, and force ambulance diversions. (2)

Similarly, a recent analysis of 12 nationally representative communities published by the Center for Studying Health System Change cites psychiatric patient volumes as part of a "convergence ... of pressures" currently taxing hospital EDs, restricting access to care, and increasing healthcare costs. (3)

Suicide is the 11th leading cause of death in the United States and the 4th leading cause of death in children, accounting for more than 30,000 deaths annually. (4-7) Every day, nearly 1,500 Americans attempt to take their own lives. (7) The majority of suicide attempts are treated in hospital EDs.

A previous suicide attempt is one of the biggest risk factors for suicide completion, (8-12) and research has demonstrated that follow-up mental health treatment after a suicide attempt can reduce the rate of subsequent attempts. (8-10,13) Therefore, it is vital that EDs have appropriate personnel to evaluate suicidal patients, and that linkages exist between emergency care and community mental health resources. Such linkages are currently inadequate.

Emergency physicians and ED staff are responsible for treating the medical complications of suicide attempts, as well as assessing the risk of subsequent suicide attempts in consultation with mental health professionals. (10,14) The ED is often the first point of contact with medical and mental healthcare for these patients. (10,15) In one study, 39% of suicide victims visited the ED at some point in the year preceding their deaths, with more than one-third of these visits for nonfatal self-harm. (16) Therefore, EDs represent an important part of access to mental health services and could play a crucial role in suicide prevention. (8,10,17)

Recently my colleagues and I from the UCLA Emergency Medicine Center and the UCLA Semel Institute for Neuroscience and Human Behavior surveyed the medical directors of all 346 California EDs (18); 223 (64.5%) responded. We found that in California EDs, there were limited mental health services for suicidal patients. Psychiatrists were reported to evaluate the majority of suicidal patients in only 10% of EDs. Most psychiatric evaluations were performed by either mobile county or private psychiatric evaluation teams (PETs), or social workers on call to the ED.

Although our study found that evaluation of patients with suicidal ideation by a mental health professional was the usual practice, 23% of the ED directors reported that they occasionally send patients with suicidal ideation home without such an evaluation. Seventy-one percent reported needing improved access to mental health personnel for evaluation of suicidal patients, 61% reported needing improved access to mental health personnel for patient disposition, and 76% reported a lack of community mental health resources to which to refer patients.

Respondents often commented on the lack of inpatient psychiatric beds available (especially for adolescent patients), the lack of community mental health resources for uninsured or Medicaid patients, overburdened PETs being slow to respond, inadequate drug and alcohol rehabilitation programs in their communities, and long delays in follow-up outpatient psychiatric appointments even for funded patients.

About one in five Americans has a diagnosable mental disorder, excluding substance use disorders. However, the majority of those with a mental health disorder do not get help. This failure of our healthcare system results from inadequate funding, lack of parity in insurance coverage, stigma, shortage of mental health professionals, and lack of political will to make mental health a priority. President Bush's New Freedom Commission on Mental Health recognized that transforming mental healthcare in America will require fundamental changes in all social services settings at the federal, state, and local levels. (19) These changes cannot come soon enough.

The hard reality is that millions of Americans who need mental health services to achieve positive clinical outcomes do not receive any, and for many the care that is furnished is inappropriate, inadequate, ineffective, or obsolete. There are many stark manifestations of our system's failure, including lives lost to suicide and the hundreds of thousands of people with a mental disorder who are homeless, unemployed, or inappropriately institutionalized or incarcerated. (20)

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1. Hazlett SB, McCarthy ML, Londner MS, Onyike CU. Epidemiology of adult psychiatric visits to US emergency departments. Acad Emerg Med 2004;11:193-5.

2. American College of Emergency Physicians, National Alliance for the Mentally Ill, American Psychiatric Association, National Mental Health Association. Emergency departments see dramatic increase in people with mental illness--emergency physicians cite state health care budget cuts at root of problem [press release]. April 27, 2004. Available at:

3. Center for Studying Health System Change. Growing pressures converge in hospital emergency departments (EDs): On-call coverage, primary care use and more seriously mentally ill patients strain EDs [press release]. November 18, 2005. Available at:

4. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Available at: Accessed November 29, 2005.

5. Hoyert DL, Mathews TJ, Menacker F, et al. Annual summary of vital statistics: 2004. Pediatrics 2006;117:168-83.

6. Institute of Medicine. Reducing Suicide: A National Imperative. Washington, D.C.: National Academies Press; 2002. Available at:

7. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Summary of National Strategy for Suicide Prevention: Goals and Objectives for Action. Available at:

8. Kapur N, Cooper J, Hiroeh U, et al. Emergency department management and outcome for self-poisoning: A cohort study. Gen Hosp Psychiatry 2004;26:36-41.

9. Brown GK, Ten Have T, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. JAMA 2005;294:563-70.

10. Buzan RD, Weissberg MP. Suicide: Risk factors and therapeutic considerations in the emergency department. J Emerg Med 1992;10:335-43.

11. Goldstein RB, Black DW, Nasrallah A, Winokur G. The prediction of suicide. Sensitivity, specificity, and predictive value of a multivariate model applied to suicide among 1906 patients with affective disorders. Arch Gen Psychiatry 1991;48:418-22.

12. Pokorny AD. Prediction of suicide in psychiatric patients. Report of a prospective study. Arch Gen Psychiatry 1983;40:249-57.

13. Guthrie E, Kapur N, Mack-way-Jones K, et al. Randomised controlled trial of brief psychological intervention after deliberate self poisoning. BMJ 2001;323:135-8.

14. Dennis M, Beach M, Evans PA, et al. An examination of the accident and emergency management of deliberate self harm. J Accid Emerg Med 1997;14:311-15.

15. Doshi A, Boudreaux ED, Wang N, et al. National study of US emergency department visits for attempted suicide and self-inflicted injury, 1997-2001. Ann Emerg Med 2005;46:369-75.

16. Gairin I, House A, Owens D. Attendance at the accident and emergency department in the year before suicide: Retrospective study. Br J Psychiatry 2003;183:28-33.

17. Kennedy SP, Baraff LJ, Suddath RL, Asarnow JR. Emergency department management of suicidal adolescents. Ann Emerg Med 2004;43:452-60.

18. Baraff LJ, Janowicz N, Asarnow JR. Survey of California emergency departments about practices for management of suicidal patients and resources available for their care. Ann Emerg Med 2006;48:452-8.

19. President's New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. Final Report. Rockville, Md.; 2003. Available at:

20. Goldman HH. Performance and outcome measurement in substance abuse and mental health programs. Testimony before the Subcommittee on Substance Abuse and Mental Health Services of the Committee on Health, Education, Labor, and Pensions of the United States Senate. July 20, 2004. Available at:



Larry J. Baraff, MD, is a Professor of Pediatrics and Medicine/Emergency Medicine at UCLA's David Geffen School of Medicine, and Associate Director of the UCLA Emergency Medicine Center.

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Title Annotation:PERSPECTIVES
Author:Baraff, Larry J.
Publication:Behavioral Healthcare
Article Type:Survey
Geographic Code:1USA
Date:Nov 1, 2006
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