In a side wing of the emergency department at St. Vincent's Charity Hospital in downtown Cleveland,
a workaday quiet prevails on a morning in the middle of the
Glenn Currier, M.D.: "There has been a tremendous proliferation of
children and adolescents presenting nationally in the emergency
There is little to distinguish the place from a general emergency
department (ED): a central desk with computers is surrounded by observation
rooms with beds, and in a nearby room a physician is evaluating a newly
Yet this is not your ordinary ED, but a specialized psychiatric emergency
department, and the people who arrive here have primary psychiatric disorders.
Like all emergency patients at St. Vincent's Charity, they enter and are
triaged through the main ED, but once admitted to the psychiatric ED, they are
treated by a staff psychiatrist, one of whom is on duty during each work
While the psychiatric ED occupies a separate space, it is not a stand-alone
operation, and the staff psychiatrist works in consultation with staff in the
general medical ED to determine the best treatment plan.
"The psychiatric ED should be a seamless part of the whole emergency
department," Philipp Dines, M.D., chair of the department of psychiatry
at the hospital, told Psychiatric News. "A stand-alone might
work well for patients with localized psychiatric problems, but that's not the
reality of the patients who come here. The reality is that patients arrive
with medical illnesses and behavioral conditions that complicate each other. I
want the psychiatric ED to be truly integrated with general emergency medical
In operation for nearly 30 years as part of the hospital's mission to serve
the community's health care needs, the psychiatric ED at St. Vincent's is the
only one in Cleveland and one of only two in Ohio.
A mobile crisis team that treats emergencies in the community has reduced
somewhat the number of psychiatric cases arriving at the hospital, but today
the psychiatric service still treats between 15 and 20 patients a day.
Patients are liable to arrive from anywhere in the city and whenever they
cannot find care elsewhere.
"We get a constant stream of patients from other places, and our
numbers fluctuate whenever there are stresses in the local health care
system," Dines said.
In this regard, the psychiatric ED at St. Vincent's mirrors a national
phenomenon: what happens in the emergency department is often the first
indicator of dysfunctions in a larger system.
One red flag that has emerged nationally is the rising number of psychiatry
patients seeking emergency care. Earlier this year a survey of emergency
physicians found that 61 percent of the 353 emergency physicians who responded
saw an increase in the number of mentally ill people seeking emergency care at
their institutions in the previous six to 12 months (FIG3). The survey,
conducted online by the American College of Emergency
Physicians (ACEP) with APA, the National Alliance for the Mentally Ill, and
the National Mental Health Association, was publicized in the March edition of
the ACEP member newsletter, reaching approximately 12,000 active members.
Of the 353 respondents, 62.7 percent attributed the escalation to cutbacks
in state health care budgets and the decreasing number of psychiatric beds.
Moreover, 67 percent reported an increase in "boarding" of people
with mental illness—the practice of keeping patients in the emergency
department until inpatient beds, or other places of care, are found.
Emergency psychiatrist Michael H. Allen, M.D., an associate professor of
psychiatry at the University of Colorado Health Sciences Center, emphasized
that the organization of emergency psychiatry services is highly variable from
one region of the country to the next, and often from one part of town to the
He said that the increase in mentally ill patients seeking emergency care
is related to the loss of public or private insurance: as individuals lose
coverage, they are liable to lose any regular source of care they might have
"But the larger problem is that health insurance comes with such poor
mental health benefits that it would be more accurate to count many people as
effectively uninsured," Allen said. "They can get medical but not
mental health care, which then forces disproportionate numbers into the
emergency system for mental health problems. All of these factors have
resulted in an increase in traffic in the emergency department related to
mental health care, and a general feeling [among medical emergency physicians]
that they are not well organized to take care of these patients." And
that is not all that accounts for the increase.
"There has been a tremendous proliferation of children and
adolescents presenting nationally in the emergency department," said
Glenn Currier, M.D., president of the American Association for Emergency
Psychiatry (AAEP). "In part this has been fueled by [the 1999 school
shooting at] Columbine, because teachers now have a policy of zero tolerance
and often bypass parents in deciding to send kids to the ED, often when
subacute emergency mental health services would have been sufficient if
Specialized psychiatric EDs, like the one at St. Vincent's in Cleveland,
are one answer to the overflow of mentally ill patients in general medical
emergency departments. The exact number of such specialized services is
unknown: the American Hospital Association stopped counting several years ago,
and many hospitals have hybrid services, including mobile crisis units or
on-site consultation services, which blur the definition of a specialized
psychiatric emergency department (see facing page).
Currier said that the most recent AHA data put the number of psychiatric
emergency departments at approximately 1,500. They tend to exist in large
urban settings at academic hospitals that have the resources to staff a
separate service and the volume of patients to make it worthwhile. Many more
hospitals—especially those in rural settings—often have a
psychiatrist available only by phone.
"We know there was a trend toward the proliferation of psychiatric
emergency services that followed deinstitutionalization and the emergence of
managed care," Currier told Psychiatric News.
Yet hospitals do not make money on such services: evaluation of the typical
emergency psychiatric patient requires more time and resources than does a
medical patient, and psychiatric EDs do not feed patients into money-making
intensive care units as do general medical EDs.
Nonetheless, Allen believes the expertise that a psychiatric emergency
service can offer is more cost-effective in the long run. "Medical EDs
aren't organized to do diagnostic assessments," he said. "They are
organized to do triage—the sickest cases go to the hospital, and
everyone else gets sent somewhere else.
"Under that model, you wind up with people being admitted to the
hospital who don't need to be, while those who don't get admitted to the
hospital are lost to follow-up," Allen said. "So triage costs you
more in the long run. You are better off devoting some resources at the front
door, doing a good assessment, and starting treatments for people."
In an environment in which mentally ill people are increasingly seen at an
acute stage of illness, the psychiatrist with a specialized interest in
emergency medicine is liable to become a critical gatekeeper.
Currier reports that the AAEP has 500 members nationally, most of whom are
practicing clinicians in psychiatric or general medical EDs. Several teaching
centers offer informal fellowships in emergency psychiatry, and the
association hopes to develop a curriculum that will serve as the basis for a
formally recognized fellowship
Though subspecialty status is a possibility in the future, the field is
likely to remain for now a stepchild of emergency medicine and psychiatry.
But Currier and Allen said that treating mentally ill people in an
emergency setting demands a unique set of skills and the ability to
collaborate with general medical staff. It is "high stakes"
medicine, in which stark decisions between admitting a person to the hospital
and releasing him or her into the community must be made within a narrow
window of time and often with a minimum of information.
Allen said emergency psychiatrists must be especially good at assessing
risk and determining the level of dangerousness to self or others. "Day
in and day out, the emergency psychiatrist deals with patients who may have
intense suicidal ideation but about whom the psychiatrist may have no prior
knowledge," he told Psychiatric News. "Your assessment
has to be finely tuned to that window of time, and the stakes are pretty high.
So the emergency psychiatrist gets good at listening carefully and using his
or her intuition about people."
As Currier observed, it is a psychiatrist's name that is liable to be on
the order that releases a patient into the community after ED assessment and
treatment. So where a patient goes afterward is critical, and emergency
psychiatry requires outreach to the community to which a patient will
At St. Vincent's Charity Hospital, the patient or visitor emerging from its
doors looks out across Interstate 90 at Jacob's Field and the Terminal Tower
on Cleveland's downtown skyline. Located in the heart of Cleveland, the
hospital is bounded by the Central and Slavic Village neighborhoods and by
Cleveland's Industrial Valley.
In addition to the inpatient psychiatric service, St. Vincent's Charity is
home to Rosary Hall, which offers inpatient detoxification and outpatient
addiction recovery programs, as well as inpatient and outpatient
But Dines said more psychiatry services are needed in the community."
People have an unrealistic view of the ED," he said. "They
think, `This person is mentally ill, and he's going to go to the emergency
department and get better.' But the ED is only the beginning, only scratching
the surface. The psychiatric ED is a useful model, but it is only as strong as
our ability to connect to the community." ▪