Imagine this scenario: a busy mom struggles to balance work and parenting during the pandemic when suddenly her teenage son begins to anger. He gets out of control, screams threats, and kicks a hole in the wall. Neighbors call the police, who recommend the family go to the emergency department (ED). When the family arrives at the ED, the stresses of enforced isolation show on their exhausted, tearful faces. And unfortunately, in these extraordinary times, they’re far from alone.

A behavioral health crash course

Thanks to the long-awaited public vaccination rollout, the number of COVID-19 cases is slowly declining. Patient visits for COVID-19-related fever, cough, and shortness of breath are decreasing at hospitals and EDs nationwide. The light at the end of the tunnel is growing brighter, and while we’re not fully out of the pandemic, the cause for optimism is growing stronger each day.

But as we begin to think optimistically, in a sobering reminder of the toll COVID infections continue to take, a new study suggests that as many as one in three people infected with COVID-19 will experience longer-term mental health or neurological sequelae. In addition, 4 in 10 U.S. adults have reported symptoms of anxiety or depression during the pandemic. This means EDs must now prepare for a behavioral health epidemic.

This new crisis will touch every demographic. Older people and those with high-risk conditions have isolated themselves as a survival imperative. Adults have struggled to balance work – often necessitating the implementation of encumbering protocols and safety measures and/or turning the home into a full-time office – with other responsibilities, including parenting duties. And in both of our EDs, we’ve seen an uptick in teenagers struggling with depression, anxiety, and self-harm. As both parents and emergency department physicians, we know firsthand that remote schooling has eroded children’s social connections and brought them into greater conflict with their families. It’s no wonder so many of these kids report crushing loneliness.

Data bear out these observations. For example, when we analyzed visit statistics from 141 EDs across 16 states, we found that patient volume declined by 40 percent overall during the shelter-in-place orders in spring 2020. However, during this same period, behavioral health visits declined by only 30 percent (and by as little as 9 percent for drug-related complaints). In general, psychiatric patients were more likely to seek care during the lockdown than those experiencing medical emergencies like strokes and heart attacks.

Preparing for this epidemic

A surge in behavioral health emergencies could be detrimental for hospitals. EDs are already struggling to manage rising numbers of psychiatric visits. Long waits and care delays have sadly become the norms for this population and lead to crowded, unsafe conditions for all. So, it’s crucial that health systems take steps now to prepare.

One key action is to reimagine staffing. Going forward, dedicated ED case managers, social workers, and behavioral health specialists could be crucial to the survival of hospitals. Although it may seem costly, appropriate staffing is advantageous for hospitals and patients, similarly to how nurse coordinators have improved outcomes for sepsis, stroke, trauma, and other high-stakes conditions. It’s past time to dedicate similar resources to behavioral health.

Another step is to collaborate with community resources. Too often, behavioral health patients are discharged into impoverished, unstable, and dangerous environments that exacerbate their conditions. In our roles, we encourage medical directors to collaborate with local mental health, substance abuse, and human services organizations to break this cycle. In fact, we’ve seen great success from holding regular meetings to develop and improve care pathways for patients.

A new paradigm for psychiatric emergencies

Most importantly, EDs must begin to see themselves as authorities in behavioral health. Contrary to current practice, only a fraction of psychiatric patients requires a time- and resource-intensive inpatient admission. ED teams can assess, stabilize, and discharge many patients for community-based follow-up with proper tools and training. Treating behavioral health complaints directly not only saves time and money, it’s far more humane.

To empower our clinical teams, we use an integrated approach to acute behavioral health care known as Emergency Psychiatric Intervention (EPI). EPI provides evidence-based training and tools to help providers assess risk, prescribe appropriate medication, and de-escalate agitation. For example, in one multicenter pilot, EPI decreased an ED’s time to discharge by 43 minutes.

When the mother and son described at the beginning arrived in my ED just outside Seattle, we put this new paradigm into action. A behavioral health specialist, nurse, and I, Dr. Miller, immediately performed a team intake. As a result, the patient had calmed down and didn’t require medical clearance or admission. If this interaction had happened a year earlier, the family would have waited hours for my medical clearance, followed later by an evaluation from a social worker. Instead, they received immediate, focused counseling and left soon after with follow-up resources in hand.

If such encounters become the norm, they could go a long way toward addressing an epidemic of behavioral health disorders. If we, through a closer emergency and psychiatry inter-specialty partnership, can encourage EDs to explore new and more humane care models, we can turn the tide now while there’s still time to prepare.

Gregg Miller and Seth Thomas are emergency physicians.

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