Emergency Room sign
By IHPL - January 3, 2022

Nearly 1 in 5 U.S. adults experiences mental illness.[1] The demand for mental health and addiction treatment services is increasing, with 67% of organizations seeing an increase in the demand for services.[2] According to a 2017 report from the National Council for Behavioral Health, there is a shortage of mental health professionals leading to a gap of up to 15,000 practitioners by 2025. This lack of access to psychiatric services is contributing to an increase in the utilization of hospital emergency departments.

During the early days of the pandemic, the overall number of emergency department (ED) visits decreased as many attempted to reduce exposure to the virus by staying away from healthcare establishments. Despite the low ED visits, the median number of visits for mental health conditions, suicide attempts and substance abuse were higher in 2020 than in 2019.[3] According to the National Syndromic Surveillance Program by the Centers for Disease Control and Prevention (CDC), an evaluation of 190 million ED visits from the end of 2018 to 2020 revealed 6 million people had at least one behavioral health symptom (i.e., mental health conditions, suicide attempts, drug overdoses, and opioid overdoses).[4] Findings showed that visits for suicide attempts, drug overdoses, and opioid overdoses between March 15 and Oct. 10, 2020, were significantly higher compared to the same period in 2019.[5]

Emergency departments throughout the United States lack the capacity to support individuals with a range of behavioral health needs, leading to poor outcomes and experience of care for individuals and families; overburdening ED staff; negatively impacting patient flow and throughput in the ED; and raising costs for health systems.[6]

For many individuals suffering from mental illness or addiction, the first point of entry into the healthcare system takes place in in the ED. Many stay in the ED for hours; some even stay there for a few days. This practice, called psychiatric boarding, occurs when an individual with a mental health condition is kept in an emergency department because no appropriate psychiatric care is available. This boarding process creates a backlog (i.e., longer wait times) of patients who are needing ED services but are unable to get in due to decreased access. Meanwhile, the individual suffering from a mental health condition or addiction is stuck in a less than optimal place where the surroundings could in fact exacerbate his or her suffering. On top of that, these patients cannot receive the care that they need in a timely manner which can lead to costly repercussions and poor health outcomes.[7],[8] 

The Patient Protection and Affordable Care Act of 2010 (ACA) and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) helped to provide better access to behavioral health services for many, yet our fractured fee-for-service and siloed payment systems along with the ongoing trend of shortages in the behavioral health workforce are continuing to exacerbate access to needed behavioral healthcare services.[9],[10] More effort needs to be put on addressing loopholes between payors and providers that perpetuate barriers to accessing affordable and effective behavioral health services. Regarding workforce shortages, leveraging technology in the form of virtual visits for low to moderate behavioral health conditions should continue to be a priority. In addition, continuing to invest in integrated care models that focus on care coordination, interprofessional collaboration, and seamless communication between medical and behavioral health providers is needed.


Author bio

Huma Shah

Huma Shah, DrPH, FACHE

Dr. Shah is the Program Director of the Master's in Healthcare Administration Program and Assistant Professor at the School of Public Health. Her research interests include organizational strategy/culture, health policy, leadership, clinical outcomes, and spirituality in the workplace.


[3] Holland, K. M., Jones, C., Vivolo-Kantor, A. M., Idaikadar, N., Zwald, M., Hoots, B., Yard, E., D’Inverno, A., Swedo, E., Chen, M. S., Petrosky, E., Board, A., Martinez, P., Stone, D. M., Law, R., Coletta, M. A., Adjemian, J., Thomas, C., Puddy, R. W., . . . Houry, D.  (2021). Trends in U.S. Emergency Department Visits for Mental Health, Overdose, and Violence Outcomes Before and During the COVID-19 Pandemic. JAMA Psychiatry, 78(4), 372–379.

[4] Holland, K. M., Jones, C., Vivolo-Kantor, A. M., Idaikadar, N., Zwald, M., Hoots, B., Yard, E., D’Inverno, A., Swedo, E., Chen, M. S., Petrosky, E., Board, A., Martinez, P., Stone, D. M., Law, R., Coletta, M. A., Adjemian, J., Thomas, C., Puddy, R. W., . . . Houry, D.  (2021). Trends in U.S. Emergency Department Visits for Mental Health, Overdose, and Violence Outcomes Before and During the COVID-19 Pandemic. JAMA Psychiatry, 78(4), 372–379.

[5] Hartnett KP, Kite-Powell A, DeVies J, et al. Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January1, 2019–May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:699–704. DOI: http://dx.doi.org/10.15585/mmwr.mm6923e1

[6] Laderman M, Dasgupta A, Henderson R, Waghray A, Bolender T, Schall M. (2018). Integrating Behavioral Health in the Emergency Department and Upstream. IHI Innovation Report. Boston, Massachusetts: Institute for Healthcare Improvement. Retrieved from: http://www.ihi.org/resources/Pages/Publications/Integrating-Behavioral-Health-Emergency-Department-and-Upstream.aspx

[7] da Silva, A. G., Baldaçara, L., Cavalcante, D. A., Fasanella, N. A., & Palha, A. P. (2020). The Impact of Mental Illness Stigma on Psychiatric Emergencies. Frontiers in psychiatry, 11, 573. https://doi.org/10.3389/fpsyt.2020.00573

[8] Nicks, B. A., & Manthey, D. M. (2012). The impact of psychiatric patient boarding in emergency departments. Emergency medicine international, 2012, 360308. https://doi.org/10.1155/2012/360308

[9] Frank, R. G., Beronio, K., & Glied, S. A. (2014). Behavioral health parity and the Affordable Care Act. Journal of social work in disability & rehabilitation13(1-2), 31–43. https://doi.org/10.1080/1536710X.2013.870512

[10] Knickman, J., K.R.R. Krishnan, H.A. Pincus, C. Blanco, D.G. Blazer, M.J. Coye, J.H. Krystal, S.L. Rauch, G.E. Simon, and B. Vitiello. (2016). Improving Access to Effective Care for People Who Have Mental Health and Substance Use Disorders. Discussion Paper, Vital Directions for Health and Health Care Series. National Academy of Medicine, Washington, DC. https://nam.edu/wpcontent/uploads/2016/09/improving-ac-cess-to-effective-care-for-people-who-have-mental-health-and-substance-use-disorders.pdf.

Retrieved from: http://www.ihi.org/resources/Pages/Publications/Integrating-Behavioral-Health-Emergency-Department-and-Upstream.aspx

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