Huge rise in mentally ill patients crowding out the ER - but few hospitals have space or therapists to treat them

Published January 04, 2019

As Featured in Daily Mail


By Mary Kekatos

Health Reporter for


Doctors say emergency rooms across the country are being crowded with mentally ill patients at unprecedented levels.


ER visits rose by nearly 15 percent between 2006 and 2014, according to the Healthcare Cost and Utilization Project.


Over the same time period, ER visits associated with mental health and substance abuse shot up by nearly 44 percent.


The result is longer wait times, limited outpatient resources, and no mental health system lodged within the emergency department.


Emergency psychiatrist Dr. Scott Zeller spoke to about how mental health patients are left agitated because there are no resources for them - and how a few tweaks can have them in and out of the ER in just a few hours.


Dr. Zeller, Vice President for acute psychiatry at medical group Vituity, says the problem with many emergency rooms is that there's a 'default' option to admit them to a psychiatric hospital.


'The ER doesn't offer much besides finding a psychiatric hospital to transfer [patients] to,' he said.


'The number of psychiatric patients has risen dramatically, however, and there's just not enough beds to hold everybody under the old rubric.'


Approximately, one in five American adults - nearly 45 million - is living with a mental illness, according to the National Institutes of Mental Health, a number that will likely continue to rise.


At the same time, a 2017 government report found that the number of ER visits related to mental health or substance abuse increased from 26.5 million visits to 44.1 million visits.


That means approximately one in eight people who visit the ER are experiencing a psychiatric emergency.


But, according to the Treatment Advocacy Center, the number of available inpatient psychiatric beds is dropping.


A January 2008 report from the nonprofit organization found that the number of inpatient beds fell by an astonishing 95 percent between 1955 and 2005.


The number dropped from 340 beds per 100,000 people to 17 beds per 100,000 people, and will likely continue to fall.


As a result, mentally ill patients often stay in the ER for hours - maybe even a couple of days - without treatment in what is known as psychiatric boarding.


'The great majority of psychiatric emergencies can be resolved in less than 24 hours as long as they get the care they need,' said Dr. Zeller.


He added that patients often end up in extreme distress due to being treated with almost criminal-like status.


'Many patients are immediately put into physical restraints or kept with a security guard,' he said.


'They need space to move around and not feel imprisoned. If they do, it could lead them to becoming even more disturbed.'


For Dr. Zeller, the answer is a psychiatric system embedded with the emergency department called an EmPATH unit, which stands for emergency Psychiatric Assessment, Treatment & Healing unit.


The unit is modeled on empathetic, home-like care to patients suffering a psychiatric emergency.


'When these folks come in, suffering, in an emergency situation, they are dangerous to themselves and others,' said Dr. Zeller.


'If we can give them prompt assessment in a comfortable environment, we've seen 75 to 80 percent of patients improve dramatically and we can discharge them to a lower level of care, which usually means home.'


Dr. Zeller estimates that currently about 12 of these units have been created by him and his team, but other units modeled on the original average at about 100.


The units can vary greatly in their design, but each one follows three basic rules.


The first is that the unit has a large central room where the patients can mill about instead of being in their own individual rooms like in a traditional ER.


'An individual room can make someone one feel more agitated,' Dr. Zeller said.


'Let's say you're suicidal. You don't feel you have a friend in the world, no reason to live. Well, when you're by yourself and the door is closed, looking at a bare ceiling, nothing about that feeling is changed.


'Having that human contact in the first hours of an emergency is very helpful.'


The second is to have staff intermingling with patients.


'There's no fishbowl situation with the nurses sitting behind a glass enclosed station. Someone can also become so agitated trying to get attention.'


Lastly, someone experiencing an emergency is able to see a psychiatrist right away.


'Let's say someone is schizophrenic. The symptoms of disease become prevalent again, they're hearing voices in their head,' Dr. Zeller said.


'They're telling them to go attack somebody or kill somebody. If the person sees a psychiatrist right away – they can de-escalate the situation and even prescribe the appropriate medication.'


Dr. Zeller says this is a practice that is less expensive and allows for immediate treatment rather than having patients have to suffer without it.


'One of the goals in emergency psychiatry is to put ourselves out of business,' he said.


'Let's not prevent emergency assistance. My basic philosophy is let's treat them so well that by time done with EmPATH unit, they don't need to return.


'They're more willing to get the help. They're connected with appropriate outpatient services whether it's to make sure they don’t run out of medication or are regularly getting intervention services.'


This article originally appeared in

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