Mental Health and Substance Abuse Referrals to Hospital Emergency Departments: A Clinical Guide for Counselors

The era of direct admission for acute inpatient level mental health and substance abuse care is long past. Since the dawn of the new century, the prevailing model for the assessment and triage of mental-health- and substance-related emergencies has been admission to a hospital emergency department, especially when a voluntary or involuntary inpatient hospitalization (i.e., civil commitment) may be warranted.

For better or worse, emergency departments have become the “gateway” for mental health and chemical dependency evaluation and triage for patients who may require inpatient-level care and/or have encountered significant difficulty accessing timely outpatient evaluation and treatment (Zhu, Singhail, & Hsia, 2016).

Objectives

Increased attention has been paid to the management of psychiatric emergencies outside of an emergency department setting (Kleespies, 2014). However, there has been considerably less discussion of issues pertaining to the evaluation and triage process of patients with mental health and/or substance use disorders (SUDs) following admission to emergency departments.

This article reviews frequently encountered patient difficulties prompting referral by counselors to emergency departments, statistics pertaining to referral patterns, and indications for emergency department assessment. It addresses the range of interventions which may be available for patients following emergency department evaluation. Reasons for transfer to inpatient and partial hospitalization care are also discussed.

Additionally, this article outlines a typology for evaluation and triage which draws on the life span developmental, medical, and psychiatric needs of patients falling within specific age groups. Recommendations are made for improving quality of care and outcomes for patients seen in hospital emergency departments for mental health and/or SUDs.

Facilitating Referrals

Counselor input regarding the reasons for referral and history plays a key role in facilitating evaluation and clinical decision making about disposition.

Referral Patterns

For a variety of reasons, including the paradigm shift whereby emergency departments have become the conduit for mental health and chemical dependency evaluation and triage (especially for prospective inpatient-level care), there has been a dramatic rise over the past decade in the number of emergency department visits for mental health and substance abuse conditions across the life span (Santillanes, Lam, Axeen, & Menchine, 2018; Weiss, Barrett, Heslin, & Stocks, 2016).

Mental health admissions to emergency departments have risen more than 50 percent in recent years (Zeller, 2018). This has involved steep increases in admissions of children, adolescents, and young and middle-age adults (Kalb et al., 2019; Santillanes et al., 2018; Weiss et al., 2016).

Reasons for Referral

Concern about recent or imminent suicidal behavior is the most frequent reason for referral and accounts for one out of every three emergency department admissions as well as numerous readmissions (Barratt et al., 2016; Zeller, 2019b). Assessment for suicidality has risen over 400 percent since the early part of the 2000s (Zeller, 2019b).

Alcohol-related problems are the most frequent reason for admission for SUDs (Moore, Stocks, & Owens, 2017). Mental health and substance abuse problems currently account for about one out of eight emergency department visits (Santillanes et al., 2018).

Frequent Clinical Presentations

The most frequent mental health presentations involve anxiety, mood, and/or stress- or trauma-related complaints and symptoms (Simpson, 2018). However, a growing number of patients seen in emergency departments have complex clinical presentations and needs that involve concurrent mental health, substance use, and medical disorders—this is sometimes referred to as “trimorbidity” (Pollak, 2015). Many emergency departments, particularly those in rural areas, lack the expertise and staffing to provide appropriate care for these patients (Hefflefinger, 2014; Zeller, 2018; Zhu et al., 2016).

Length of Stay

Mental health and dual-diagnosis patients are more than twice as likely as medical patients to require transfer to inpatient-level care (Zhu et al., 2016). Many of these transfers involve patients with suicidal thinking and behavior (Simpson, 2018).

For a number of reasons tied to the seemingly intractable systemic problems within the mental health care system, emergency department evaluation and triage of mental health and substance abuse cases frequently involve protracted stays. Even relatively straightforward voluntary admissions can take a day or more to arrange despite the zealous efforts of clinical staff to facilitate a transfer.

Mental health and substance abuse problems currently account for about one out of eight emergency department visits.

Nationwide, the average length of stay in emergency departments for transfer to inpatient-level treatment is seven to thirty-four hours, which is two to three times longer than transfers for specialized medical care (Zeller, 2018). Cases that primarily involve elevated risk for suicidal self-harm are associated with lengthier stays than cases that do not involve this safety issue (Smith et al., 2016). Overall, length of stay is considerably higher for psychiatric patients than for medical patients (Zhu et al., 2016).

All too often patients become “psychiatric boarders,” especially patients slated for an involuntary admission, awaiting a far-from-guaranteed transfer over days or weeks while receiving little or no concurrent treatment (Zeller, 2019a). These prolonged lengths of stay have contributed substantially to overcrowding in emergency departments (Nolan, Fee, Cooper, Rankin, & Blegen, 2015).

Extended stays have also led to increases in iatrogenic effects (i.e., the unintended negative consequences of health care interventions), notably a deterioration in the neuropsychiatric condition of some patients and worsening feelings of demoralization, disdain, and mistrust of the system of mental health and chemical dependency care by patients, their loved ones, and health care providers.

Indications for Emergency Department Admission

A sizable number of emergency department admissions involve mental status changes, which are linked to medication- and substance-induced and/or other potentially life-endangering medical factors, especially among adults with preexisting conditions and the elderly (Pollak & Miller, 2011; Pollak & Miller, 2019a). Indications for emergency department admissions that are potentially lifesaving are cited below:

• Persistent or recurrent confusion and disorientation
• Disorganized, paranoid, and/or psychotic thinking and behavior
• Marked anxiety, panic, mood instability, and/or significant agitation and irritability
• Suicidal and/or homicidal thinking and behavior
• Life-endangering inability to care for oneself

Intervention Options

The range of intervention options which, in principle, can be considered for patients being evaluated in emergency departments are listed below:

• Overnight stay for observation followed by reassessment the following day
• Medication treatment for acute symptoms (e.g., agitation, irritability, sleep disturbance, psychosis, substance withdrawal, etc.)
• Medication-assisted treatment for alcohol and/or other SUDs
• Medical admission for detoxification and/or for further evaluation of a possible medical- or substance-related contribution to symptoms
• Inpatient hospitalization on a voluntary or involuntary basis
• Transfer to an inpatient/residential SUD program
• Transfer to a partial hospitalization program or intensive outpatient program (IOP)
• Crisis bed placement
• Follow-up safety evaluation and/or one or more crisis stabilization appointments in a community clinic, mental health center, or via telehealth
• Community mental health center open access evaluation
• Prompt return to established mental health and/or substance use providers
• Mutual-aid groups like Alcoholics Anonymous and Narcotics Anonymous
• One or more wellness check-in phone calls or telehealth contacts from emergency department mental health staff following discharge
• Use of 24/7 telephone crisis hotlines

Crucially, while most emergency departments are able to provide basic mental health and substance use assessment services, many are not in a position to address the range of previously listed treatment and disposition issues. Few emergency departments have access to psychiatrists or advanced practice registered nurses with specializations in psychiatry who can conduct face-to-face evaluations and/or are available 24/7 for on-call phone consultations. Furthermore, many emergency departments are not part of medical facilities that have inpatient mental health units (Zeller, 2018).

Many emergency departments also lack dependable follow-up services within the hospital or the community in the event of same-day or next-day discharge. This includes the availability of staff for wellness check-in calls or one or more face-to-face or telehealth crisis stabilization and/or safety assessments. This situation leaves many patients in limbo regarding timely follow-up services.

Levels of Care

Transfer to an inpatient mental health service on a voluntary basis is the disposition of choice for patients meeting one or more of the following criteria:

• Acute risk for harm to self or others and/or significantly impaired everyday functioning due to one or more mental health and/or SUDs
• A history of help seeking and treatment compliance together with good family and/or social support
• Some preserved insight and a credible stated willingness to be admitted even with psychotic symptoms

Partial/day hospitalization is generally a better option for patients without concerning safety issues, acute psychosis, and/or significant functional impairment who are help-seeking, have relatively preserved insight into their condition, have a history of satisfactory compliance with treatment, have good family and/or social support, and also have access to transportation to keep daily appointments. As with voluntary inpatient-level admission, the patient credibly consents to enter services of this kind.

An involuntary admission (i.e., civil commitment) is indicated for patients who decline a voluntary admission and who meet one or more of the following criteria:

1. They are acute and imminent dangers to themselves
2. They are acute and imminent dangers to others
3. They are too impaired with regard to self-care, insight, decision making, and judgment due to one or more mental health and/or SUDs to appreciate the need for timely, inpatient-level care

Typologies in Emergency Department Mental Health Care

Typologies in mental health and substance abuse care are designed to identify relatively discrete groups of patients based on specific diagnostic criteria, as is the case with the DSM-5 (APA, 2013). These diagnostic models are of limited utility, however, for guiding decisions in emergency departments regarding type and level of care and disposition.

Emergency mental health and substance abuse assessment and intervention should be a required component of training programs . . .

Moreover, typologies to facilitate decision making are far from perfect. They are limited in their clinical utility by the resources available for assessment and treatment in most emergency departments as well as by the challenges posed by the unique clinical profile and life circumstances of individual patients. These include life span, developmental, and medical status as well as situational stressors that significantly influence decisions regarding diagnosis and disposition.

That said, when one considers the problems inherent in having a hospital emergency department serve as the conduit for referral and triage of large numbers of patients, across the life span, with mental health and/or chemical dependency problems, a typology is needed that is informed by real world clinical experience and that can facilitate expeditious and safe clinical decisions.

In addition, counselors working in a range of settings can benefit from a typology predicated on the developmental, medical, and psychiatric needs of patients within broad age groupings that can enhance decision making regarding referral. These typologies can also inform counselors as to the probable outcomes for their patients following emergency department admission.

Age Groupings

Preschool-Age Children (Ages Two to Four)

Children within this age range have low rates of admission to emergency departments for mental health assessment. Of those who are admitted, hospitalization options are scarce as there are few inpatient mental health services that take children younger than five years old.

Moreover, there is concern about iatrogenic effects from a hospitalization due to separation from parents and other attachment figures. Also, hospitalization is rare within this age group, as the difficulties that trigger an emergency department admission often spontaneously improve fairly quickly and/or can be satisfactorily addressed via outpatient mental health services including home-based crisis services.

School-Age Children (Ages Five to Eleven)

Among elementary and early middle-school-age children, the most frequent reason for referral involves disruptive behavior, which typically takes the form of emotional dysregulation (i.e., “meltdowns”) sometimes accompanied by suicidal and/or homicidal threats. Less common are concurrent instances of deliberate suicidal self-harm and/or interpersonal violence.

Based on the DSM-5 (APA, 2013), many of these children fall within the disruptive, impulse-control, and conduct disorders classification, while some meet criteria for a disruptive mood dysregulation disorder and/or unspecified trauma- and stressor-related disorder. Some of these children also have co-occurring neurodevelopmental disorders like attention-deficit/hyperactivity disorder, autism spectrum disorder (level I), one or more specific learning disorders, and/or intellectual disability (mild severity).

After several hours in the emergency department, many of these children successfully return to their baselines and hence are not deemed to be imminent, serious threats to themselves or others. Children with this recovery trajectory rarely benefit from and are unlikely to meet criteria for a transfer to an inpatient mental health service. Most of the time they can be safely discharged to home and school monitoring.

Children who are established in outpatient and/or school-based mental health services should be referred back to their providers, ideally with an expedited appointment that is arranged while these children are still in the emergency department.

If there are no outpatient- and/or school-based services in place, efforts should be made to establish such services prior to or shortly after children are discharged from the emergency department. When possible, this should be coupled with a wellness/check-in call or a crisis stabilization appointment the following day with children and their parents or legal guardians. Children who are deemed imminent and concerning dangers to themselves or others, display persistent or worsening emotional dysregulation during their time in the emergency department, and/or who appear psychotic should remain overnight while a search is undertaken for a transfer to an appropriate inpatient mental health service. Still, a discharge is possible the following day in the event that reassessment is indicative of a substantial improvement in clinical status and there is also the option of these children resuming or transitioning to outpatient services in a timely manner.

Adolescents (Ages Twelve to Nineteen)

Patients within this age range are most frequently referred for nonsuicidal self-harm (typically superficial cutting), sometimes accompanied by suicidal threats and/or behavior. Less common are threats of and/or engagement in interpersonal violence directed at family members and/or school peers and, on rare occasions, at these teenagers’ schools.

An important subgroup are LGBTQ teenagers with worsening baseline symptoms of anxiety and/or depression frequently accompanied by nonsuicidal self-injury and/or suicidal thinking. These difficulties and symptoms are often related to real or perceived peer rejection and harassment.

Another important subgroup are older adolescents with worsening anxiety and mood symptoms and decompensated defenses or coping strategies referable to probable emergent “Cluster B” personality difficulties, notably borderline patterns and traits. Within this subgroup, admission is usually triggered by psychosocial stressors related to attachment and loss issues and/or precipitous lowering of self-worth in the context of peer rejection and harassment, family conflict, and/or academic and other learning problems. Many of these teenagers report being increasingly stressed and overwhelmed with their lives.

In addition, first episodes of major mental illnesses—notably feeding and eating disorders, major depression, bipolar disorder, and schizophrenia as well as SUDs—become increasingly more common through the adolescent period.

As for disposition, the same general rules of thumb outlined previously regarding school-age children are applicable to adolescents. Still, a transfer to an inpatient mental health service is more frequently indicated in view of the greater likelihood of a first episode of a major mental illness (especially among older teenagers) as well as the greater capacity of adolescents to develop and act on a serious plan to harm themselves and/or others (sometimes in the context of substance abuse) than is the case for younger children. Also, some adolescents may be sufficiently impaired by substance use to warrant immediate medical treatment including detoxification services.

Adults (Ages Twenty to Forty)

Among this population, frequent reasons for referral include a first episode or recurrent episode of major mental illness sometimes complicated by substance abuse and/or personality disorder. A subset of adults present in a highly disorganized and emotionally dysregulated manner—some have transient dissociation and/or brief psychosis linked to substance abuse. A substantial number of these patients have a “Cluster B” personality disorder contribution to their difficulties.

Inpatient and even partial hospitalization programs are wary of taking these patients due to their penchant for angry, demanding, and disruptive behavior. At best, these programs will reluctantly agree to an admission only to discharge these patients after a day or two. Many of these patients will also decline a voluntary admission and usually do not meet criteria for an involuntary admission.

In view of these disposition problems, and when there are no acute safety issues or established outpatient providers to whom these patients can quickly return, a discharge followed by one or more wellness/check-in calls and/or crisis stabilization visits as a “bridge” to outpatient services is often the only realistic treatment option. When available, same day or next day open access evaluation for outpatient services at a community mental health center can also be a viable option.

Another common clinical presentation involves adults who are admitted in an intoxicated state—usually with blood alcohol levels over three hundred—who have made suicidal statements and may have also engaged in nonsuicidal self-injury and/or suicidal behavior while intoxicated.
Many of these patients have baseline mood, anxiety, and/or personality disorders as well as alcohol-related and sometimes other substance dependency problems. They rarely, if ever, become dangerously despondent and self-injurious except when they are drinking.

Once sober and seen for a bedside evaluation, these patients typically report having poor recall of what they may have said or done while intoxicated and credibly deny current hopelessness, depression, or suicidality. They nearly always report feeling better emotionally, usually decline a possible inpatient or partial hospitalization, and rarely meet criteria for an involuntary admission. Most of these patients are discharged from emergency departments and return home with a safety plan once they have sobered up and have been formally assessed regarding their safety and treatment needs.

When willing to consider treatment, disposition options for these patients include the following: inpatient admission for detoxification, a return to existing treatment services, and (when not in treatment) referral preferably for dual-diagnosis intervention on either an inpatient or outpatient basis depending on availability and these patients’ clinical profiles and life circumstances.

Exceptions to these disposition rules include patients with serious medical complications due to persistent and chronic alcohol use and who require a medical admission. It also includes patients who have made a serious enough suicide attempt to warrant transfer to an inpatient unit.

Middle-Age Adults (Ages Forty to Sixty-Five)

For most middle-age adults, the reasons for referral and decision making regarding disposition are comparable to younger adults. On the other hand, by late middle age a small but clinically important subset of adults in their fifties and sixties present with mental health symptoms that may mask or co-occur with unappreciated, insidious-onset, neurocognitive change.

Some of these patients are experiencing an initial episode of major depressive disorder (severe) with melancholic and/or psychotic features which can presage an eventual neurodegenerative decline—so-called “depressive dementia.” Other patients are in the early stages of a primary neuro-degenerative disorder that can be associated with significant psychiatric comorbidity and/or substance use and that may obscure underlying cognitive difficulties. This includes early phase Alzheimer’s disease, cognitive change due to other neurodegenerative influences as well as the effects of medication, alcohol, and illicit substances.

These patients nearly always need inpatient level care. Some may require an involuntary admission due to poor insight and inability to appreciate their need for more in-depth evaluation and treatment.

Older Adults (Ages Sixty-Five and Over)

Common clinical presentations within this age group include recurrent episodes of minor and major mental health conditions or worsening of chronic baseline mental health conditions in response to the psychological impact of medical stressors, the direct physiologic effects of medical factors, and/or psychosocial precipitants related to deaths and other significant losses. Medical factors, especially early stage neurocognitive disorders that precede the onset of mental health complaints or symptoms, occur concurrently with or develop soon after the onset of mental health complaints and symptoms, are common in this age group, as is concerning cognitive change with functional impairment, but with little or no significant psychiatric comorbidity.

Many older adults, especially those with complex medical and psychiatric presentations that may also involve substance abuse and self-harm concerns, require transfer to an inpatient, geriatric psychiatry service. Those with significant medical comorbidity should preferably be admitted to a medical and psychiatric unit, although few communities are fortunate enough to have this type of specialized, dual-diagnosis, inpatient service. It is ill-advised, however, to transfer elderly patients with minimal (if any) cognitive impairment to inpatient, geriatric psychiatry services that routinely admit patients who meet DSM-5 criteria for major neurocognitive disorder.

Older adults without safety issues or significant cognitive difficulties, who have good family and social support, and generally have milder and less complicated clinical presentations can be safely discharged to outpatient programs. These should preferably be geared (when available) to the life span developmental and mental health needs of this age group.

Future Directions/Recommendations

Emergency departments in general medical hospitals with a high volume of mental health and substance abuse referrals should have salaried, in-house, 24/7 behavioral health teams including alcohol and drug counselors. On-call psychiatrists and psychiatric nurses should be available for medication recommendations by phone, for assessment via telepsychiatry for routine cases, and for face-to-face evaluation for clinically complicated patients (Pollak & Miller, 2017; Zeller, 2019b).

Greater attention needs to be paid to establishing emergency and psychiatry assessment, treatment and healing units (EmPATH units) within emergency departments for patients who have been medically cleared and are reasonably stable. These are relatively separate and distinct short-stay units for specialized psychiatric care that offer a therapeutic milieu for patients who may be staying overnight in an emergency department for reassessment, are awaiting transfer to inpatient-level care, or who may improve sufficiently within a day or two to allow for discharge directly from the emergency department with an aftercare plan. Data is accruing that these units reduce psychiatric boarding as well as the need for admission to inpatient-level care (Zeller, 2019b).

Hospitals should also have short-stay mental health beds for voluntary patients meeting specific criteria who can benefit from relatively brief hospitalizations. These patients would be admitted directly from the emergency department or from an EmPATH unit and then discharged within a few days to outpatient services ideally within the same health care system.

The ongoing movement to integrate mental health and substance abuse services in outpatient medical settings (notably primary care “medical homes”) will likely help to reduce the need for emergency department evaluation. It would also be helpful to “carve out” state-funded mental health clinics on the grounds of medical centers or at least situate these clinics in close proximity to hospital emergency departments to expedite assessment and a transition to outpatient services.

Emergency mental health and substance abuse assessment and intervention should be a required component of training programs as part of a broader effort to advance the medical literacy of counselors and other nonmedically trained clinicians, as these providers are responsible for most of the direct clinical assessment and triage in emergency departments (Pollak & Miller, 2019b). This should be coupled with expanded opportunities for continuing education credit in emergency mental health and substance abuse evaluation and triage for these clinicians.

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