Current Status of Psychiatric Care in the United States
A recent national survey found that 11.8 million adults felt they needed mental health treatment, and that this need was not met. As a result, patients will likely seek treatment elsewhere, often in a hospital’s emergency department. For instance, in 2018, 4.9 million emergency department visits were related to mental health or other behavioral issues. Emergency departments are often ill-equipped to deal with these patients, and because of the lack of available beds in psychiatric treatment centers, the patients are often left sitting in the emergency room waiting for a transfer to a qualified facility. Emergency departments are typically overwhelmed with patients, and psychiatric emergencies put a further strain on them.
Access to Care is Reduced because of a Deficit in the Number of Psychiatrists and Lack of Availability in Treatment Facilities
In 2020 there were an estimated 25,540 psychiatrists in the United States, a significant reduction from 2018, where there were approximately 30,415 psychiatrists. It is estimated that by 2025, the total deficit of psychiatrists will be 6,090 to 15,600, even though there has been an uptick in physicians completing psychiatric residencies. In the 2020 residency matching cycle for medical school graduates, there were 1,858 psychiatric residency positions offered, which was a 74 percent increase over 2008 statistics. The increase in available positions reflects the growing need for psychiatrists. However, only 61.2 percent of the positions were filled.
This shortage is not a new issue; courts have been aware of it since at least 1966 (“We are aware of the shortage of psychiatric personnel is a most serious problem today in the care of the mentally ill.”) Sixty percent of the counties in the United States do not have any psychiatrists. This is especially impactful on rural areas; 80 percent of them do not have any psychiatrists. Moreover, 59 percent of practicing psychiatrists are age 55 or older and closer to retirement age, worsening the situation.
The number of beds for inpatient mental health services has also decreased, leading to a lack of availability for treatment in treatment centers. For example, between 1998 and 2013 there was a 35 percent drop in the number of beds available in inpatient psychiatric facilities in the United States. In 1970, there were approximately 413,000 treatment beds; by 2016, there were 37,679.
The Cost of Treatment is a Barrier to Adequate Care
Healthcare generally is expensive, and mental healthcare is not an exception. One study found that of the 11.8 million adults with an unmet need for mental health treatment, 38 percent could not afford treatment.
Most people will pay for mental health care through their group or individual health insurance plan. Congress enacted the Employee Retirement Income Security Act of 1974 (ERISA) to “regulate employee pension and welfare benefits, and designed it to promote the interests of employees and their beneficiaries.” ERISA set minimum standards for private industry health plans.
In 2008, ERISA was amended by the Mental Health Parity and Addiction Equity Act (MHPAEA). The purpose of the Act, which applied to group health plans, was to “end discrimination in the provision of insurance coverage for mental health and substance use disorders as compared to coverage for medical and surgical conditions in employer-sponsored group health plans.” The MHPAEA mandates that if a plan’s coverage “does not include aggregate lifetime limits on substantially all medical and surgical benefits, the plan or coverage may not impose any aggregate lifetime limit on mental health or substance use disorder benefits.” The Act also provides that if out-of-network services are covered for other care, out-of-network mental healthcare must also be covered. The MHPAEA “d[id] not mandate, or require, coverage of any specific service or treatment, but merely states that if a certain service or treatment is covered, it must be covered equally for medical and mental health conditions.”
Additional changes came with the passing of the Patient Protection and Affordable Care Act (PPACA) which mandated the coverage of mental health services as one of 10 “Essential Health Benefits.” PPACA amended the MHPAEA to apply to individual insurance plans as well as group health plans. PPACA also prevented plans from discriminating against those with preexisting conditions, which includes preexisting mental illness. However, while insurance coverage of mental health treatment has improved significantly, the cost remains too high for a large portion of those needing care.
There are Insufficiencies in Care in Emergency Departments
If someone is seeking psychiatric care in a hospital emergency department, chances are that the individual will not receive ideal or even adequate care for his/her condition. This is due to several factors, including undertrained staff, lack of personnel qualified to treat or diagnose the condition, and a delay in care because the condition is not deemed severe enough for immediate treatment. The lack of properly qualified medical professionals is especially apparent in rural areas or smaller hospitals, which might have to outsource psychiatric care to a county evaluator.
Another issue affecting mental healthcare in emergency departments is the duty to stabilize a patient under the Emergency Medical Treatment and Labor Act (EMTALA). EMTALA requires that hospitals opting to participate in Medicare and Medicaid meet two requirements when treating someone seeking treatment in an emergency room. The first requirement is that the hospital provides an “appropriate medical screening examination to determine whether or not an emergency medical condition exists. The second requirement arises if the patient does have an emergency medical condition; if so, “the hospital must provide either (A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or (B) for transfer of the individual to another medical facility.”
The statutory definition of an emergency medical condition under EMTALA is “a medical condition manifesting itself by acute symptoms of sufficient severity…such that the absence of immediate medical attention could reasonably be expected to result in (i) placing the health of the individual…in serious jeopardy, [or] (ii) serious impairment of bodily functions…”
Although not explicitly stated in the language of EMTALA, it has been held that a mental health emergency does qualify as an emergency condition. Further, an emergency medical condition in the psychiatric context has been interpreted to mean that an individual poses a danger to himself or others.
Under the statute, a patient has been stabilized when it is evident that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility.” The Centers for Medicare & Medicaid Services has stated that ‘‘for purposes of transferring a patient from one facility to a second facility for psychiatric conditions, the patient is considered to be stable when he/she is protected and prevented from injuring himself/herself or others.”
A patient may not be transferred from the emergency department unless requested by the patient or the patient’s representative, or if the “medical benefits available at the other facility outweigh the risks of transfer.”
Patients presenting with mental health concerns are likely to be best served by being transferred out of the emergency department of a general hospital into a more qualified facility such as a hospital’s psychiatric ward or a psychiatric hospital. But if there is no availability in these facilities, patients will be boarded in the emergency department until they can be transferred, thus delaying treatment. Additionally, when a patient is left waiting for transfer, his/her condition may change.
There is no agreed-upon definition of what constitutes boarding, especially with regard to how much time a patient spends in the emergency department before seeing a mental health provider. Some say boarding begins at four hours; others say boarding begins around 24 hours. A general definition of boarding is “patients being held in the emergency department or another location after the decision to admit or transfer has been made.” One study found that due to a lack of availability, 60 percent of patients waited over 10 hours in the emergency department to be seen by a mental health professional, which constituted boarding.
Civil commitment arises out of two legal principles, Parens patriae and a state’s police power. The doctrine of Parens patriae gives a state the power to “act as a guardian for those who are unable to care for themselves….” The police power allows states to enact regulations “[to] protect the public health and the public safety.”
In the asylum era, all admissions to institutions were essentially involuntary because it was believed that those afflicted with mental illness lacked the capacity to make decisions.
The Supreme Court laid out general guidelines for civil commitment in O’Connor v. Donaldson. In this case, Kenneth Donaldson was confined in a state facility in Florida for 15 years, and although he would have otherwise been eligible for release because he was not dangerous or violent, he remained institutionalized. Rather than actually receiving care or treatment, Donaldson was merely confined. The Court stated that “a state cannot constitutionally confine without more a non-dangerous individual who is capable of surviving safely in freedom by himself or with the help of willing and responsible family members or friends.”
The standards for civil commitment set by the Supreme Court were that an individual presenting with a mental illness “must either present a known risk of harm to him or herself or others, be in such a state that she would be ‘hopeless to avoid the hazards of freedom,’ or in need of psychiatric treatment.”
The standards for civil commitment today are left up to individual states, but most include the requirement of “dangerousness.” For example, in Oregon the statute first requires that the court determine whether the individual in question meets the definition of a “person with mental illness.” The statutory definition is a person “who because of a mental disorder” is “dangerous to self or others,” “unable to provide for basic personal needs that are necessary to avoid serious physical harm in the near future, and is not receiving such care as is necessary to avoid such harm.” The problem with this definition is that the dangerousness requirement is exceptionally broad because there is no statutory timeframe for the imminence of the risk nor does the statute explain what may constitute a danger. This subjectivity of what qualifies is not exclusive to the Oregon statute.
During the 2021 legislative session the Oregon Senate introduced a bill that would have added more specificity. The bill proposed to define “dangerous to self or others” as “likely to inflict serious physical harm upon self or another person within the next 30 days.” The bill was in committee upon adjournment in June 2021.
In addition to the standards required to civilly commit individuals, courts have also provided that individuals subject to commitment have a right to treatment. Rouse v. Cameron established a statutory right to treatment in criminal civil commitment cases. The right “could be satisfied by bona fide efforts of the hospital staff to provide adequate treatment consistent with the present state of medical knowledge.” The court in Rouse also addressed the potential constitutional issues arising out of the failure to treat those who have been involuntarily committed, and in the case of those who are committed due to criminal convictions, the lack of treatment may even amount to cruel and unusual punishment under the Eighth Amendment.
Courts further addressed the constitutionality of requiring treatment in Wyatt v. Stickney, stating “[t]o deprive any citizen of his or her liberty upon the altruistic theory that the confinement is for humane therapeutic reasons and then fail to provide adequate treatment violates the very fundamentals of due process.”
Overall, civil commitment is problematic, especially when an individual does not want treatment and has the capacity to make his/her own decision.
While Alternatives to Seeking Crisis Treatment in Emergency Departments Exist, There are Still Issues
Emergency mental health treatment is a complicated matter because of an extreme range of symptoms and reactions exhibited by patients, and there is no clear solution for emergency mental healthcare as a whole.
There are a few alternatives to seeking treatment for mental health crises in an emergency department. And like the emergency department, these services have a range of capabilities when it comes to treatment. While some of them work in theory, they are not a panacea, especially when it comes to funding. They also don’t eliminate the shortfalls in the availability and adequacy of emergency psychiatric care.
Alternative Psychiatric Crisis Services
One alternative to the use of the emergency department is the use of crisis telephone lines such as the national suicide prevention hotline and mental health crisis phone line. To ease the use of the national hotline, Congress in 2020 passed the National Suicide Hotline Designation Act, designating a universal telephone number for the national suicide prevention hotline, so rather than a traditional 10 digit number, the hotline number is 9-8-8. The Act mandates national implementation of the number by July 2022.
Additionally, to avoid an emergency department, care is available in a “walk-in” model through clinics or psychiatric urgent care. These facilities focus on stabilizing a mental health crisis in a less intense setting. However, when necessary, hospitalization might be recommended.
Another option is an extended observation unit or “23-hour crisis stabilization” such as the Alameda Model, discussed below. These units work to quickly stabilize the patient in an effort to avoid hospitalization.
The Alameda Model
One promising alternative to reducing boarding in emergency departments is the creation and use of regional psychiatric emergency services (PES) units. This model, called the Alameda Model and put into practice in Almeda, California, is designed to reduce emergency department visits and reduce emergency department boarding by creating a specific treatment center that acts as an outpatient treatment facility with an expedited timeline aiming to have patients treated and discharged in less than 24 hours. Typically patients are transferred from the emergency department as soon as they are medically stabilized, although a patient may “self-present.” The Almeda PES unit is located at John George Psychiatric Hospital, part of the Almeda Health System.
The Model seeks to enable approximately 75 percent of patients to reach a level of stability so that they can be discharged either to their home or to a community program within the 24-hour timeline. Because of the intensive treatment provided at these facilities, there are lower rates of hospitalization, and under 30 percent of patients are admitted to inpatient care.
Additionally, the 24-hour timeline allows for “(1) [the patients to be] treated in the least restrictive setting; (2) disruption to their lives is minimized, (3) psychiatric boarding in hospital EDs is eliminated, [and] (4) unnecessary psychiatric hospitalizations are prevented.” One study found that wait times for treatment at the PES unit averaged less than two hours and that less than 25 percent of the patients were admitted for further treatment in an acute psychiatric care facility.
Problems with the Alameda Model
Based on the reported success of the Alameda Model designed to be a “humane, compassionate alternative” to emergency department treatment, four Oregon-based healthcare systems collaborated to create a PES unit for the Portland area emulating the Model. The facility, Unity Center for Behavioral Health, opened in January 2017. It had a living room-type waiting room with 40 reclining chairs as well as eight rooms designed to calm patients, among other uses.
However, the John George PES unit in Almeda was not faring well. In 2015, several issues at the unit were publicly reported, including severe overcrowding, physical and sexual assaults, and various employee safety violations. One source quoted a staff member describing the conditions as “inhumane and befitting a third world country.” Whether the representatives from the Oregon healthcare systems trying to emulate the Model were informed of these problems is unclear; however, a former nursing supervisor at John George reported informing one of the Oregon officials about them.
Since its opening in 2017, The Unity Center for Behavior Health has been plagued with its own problems, including financial issues, safety concerns, and much like traditional emergency departments, overcrowding. Some patients are boarded in the reclining chairs in the waiting room, sometimes for nearly a week, and some patients are being diverted back to emergency departments.
The major issue in sustaining Unity is funding. The estimated operational losses were $6 million; however, during the 2019 fiscal year, the operating losses were $35.3 million and the projected 2020 losses were $21.4 million. Part of the funding deficit is due to reimbursement from the state for patients waiting for transfers to the Oregon State Hospital, a state psychiatric hospital. Committed patients cost Unity $1,500 daily, and the state reimburses $834.
Unity has also not been immune to safety issues. In the first seven months of operation, there were hundreds of assaults, for which Unity was fined $1,650. Two former nurses filed lawsuits against Unity for allegedly being wrongfully terminated because they had complained about the unsafe conditions.
Other critics have called the living room model “chaotic” and “unsafe”. In 2018, the Oregon Health Authority (OHA) investigated Unity after receiving a complaint about patient safety, including patients having access to items that they could use to harm themselves, lack of protection of patient rights, and improperly trained staff restraining patients. Unity was set to lose its certification, but corrected the major safety concerns before the deadline.
While PES units are promising, they don’t take the place of treatment when appropriate in acute care facilities and state hospitals. However, more such treatment beds need to be available. Without an expansion of these services, the healthcare ecosystem is left with a problem of patients being boarded in one emergency care setting or the other.
Suggestions for Progress
To aid in solving some of the issues outlined above, several changes need to be made to the current mental healthcare system. Solutions include increasing the number of providers and expanding care facilities, further education for those encountering mental health patients in emergency settings, and addressing issues of cost and funding. Specifically for issues of funding and civil commitment, solutions will likely require legislative changes.
Access to Care
A major issue in the mental healthcare system has arisen due to the lack of availability when it comes to providers and treatment facilities. The shortage of providers must be the primary focus; without adequate numbers of treating providers, the increase in treatment beds would not be effective.
Psychiatrists are not the only option for mental healthcare and treatment. Other mental health professionals include psychologists, primary care providers, psychiatric pharmacists, and nurse practitioners. However, the use of these providers still does not fill the gap.
There are some other ways to increase access to care. One study suggested seeking out foreign-trained immigrant psychiatrists through the creation of a healthcare visa program similar to the existing agriculture and hospitality sector programs.
Another option is to expand telepsychiatry services, which would be particularly helpful for rural or other areas without a psychiatrist or other qualified mental healthcare provider. This approach does have some limitations. First, the provider may not be able to get a full picture of the individual because of the visual limitations of telehealth. For example, the provider may not be able to read a patient’s body language. A more widespread issue with telemedicine is with the technology itself. A patient needs a device to access the software, a stable internet connection, and the technical abilities to operate the device and the program. This may be especially problematic for lower-income individuals who may not have such access or ability.
A further way to increase access to treatment is to increase preventative screenings. Currently, under PPACA the only mandatory preventative mental healthcare is the primary care provider’s depression screening. This is a questionnaire filled out by a patient listing general symptoms of depression and asking patients if they have experienced the symptoms of depression “not at all,” “several days,” “more than half the days,” or “nearly every day.” Simply screening for depression and nothing else is insufficient. These screenings need to be broadened to include other mental illnesses. Like any other condition, if discovered and diagnosed early enough, the symptoms can often be mitigated which in the long run may save someone from having to seek care in an emergency department setting.
The cost of medication can also adversely affect access to mental health treatment and should also be addressed. Although a significant portion of prescription medication is covered by insurance plans, the cost of the medication is often unreasonable. Legislative attempts to control drug prices have failed largely because of challenges made by pharmaceutical companies.
To solve knowledge gaps that limit holistic assessment and treatment, there needs to be more education for providers in emergency departments. This training could include topics like the most up-to-date treatment methods, sensitivity training in order to destigmatize mental illness, and de-escalation tactics to avoid chemical or physical restraint of patients without their consent. For physicians specifically, the education in psychiatry or emergency psychiatrics needs to be more than the minimum rotation time during their residency. Emergency departments can also consider trauma informed care when dealing with a mental health emergency. Trauma informed care looks at the impact of the trauma and ways to recovery; looks for the signs of trauma; “integrate[s] the knowledge about trauma into policies, procedures, and practices”; and works to avoid re-traumatization of the patient.
Those who may make initial contact with a person presenting with a mental illness, like paramedics and police, should also receive additional education in mental health. The training should focus on de-escalation and compassion. This type of training is of the utmost importance because it can aid in removing the criminalization of mental illness. For example, training could include methods of how to transport people having a mental health crisis without the use of handcuffs or putting them in the back of a police car as if they were arrested.
Another way to improve mental healthcare is the allocation of funds for the expansion of care facilities and additional funding for emergency departments so that they are better prepared to treat and stabilize patients and to avoid transfer to an acute psychiatric care facility.
There has been some progress in this regard. In an effort to help with economic recovery due to the impact of the COVID-19 pandemic, Congress passed the American Rescue Plan Act of 2021. In this Act, Congress allocated funds specifically for mental healthcare. The Act provides $1.5 billion for community mental health services to be spent by September 30, 2025 and $420 million for the expansion of certified community behavioral health clinics.
The Act allocates $80 million to further training and education of healthcare providers and public safety officers using “evidence-informed strategies for reducing and addressing suicide, burnout, mental health conditions, and substance use disorders among health care professionals.” The Act also provides $20 million for an “education campaign directed at health care personnel and first responders to encourage identification and prevention of behavioral health disorders[.]” The Act provides an additional $15 million for states to develop mobile crisis service programs and, if a state implements a program, the Act provides for an enhanced federal Medical Assistance Percentage for Medicaid home and community based services. Finally, $80 million is allocated for pediatric mental health services.”
Although the United States has moved beyond the days of lobotomies and other horrific treatment plans of early mental healthcare, there are still areas that can be greatly improved. To create a sustainable mental healthcare system in the United States, the workforce needs to be expanded, there needs to be more availability of treatment, and if that treatment is not immediately available or accessible in a crisis, a patient needs to be able to seek care in a well-funded, safe environment.