mentalemergency

People Are Using the ER for Mental Health Crises. Experts Say It’s One Of the Biggest Problems in Emergency Medicine

It helps neither the patient nor the caregivers, leaving ERs short-handed and those in the throes of a panic attack (or worse) without the treatment they need

Maxx Budline was staring down at the multicolored map of the board game Risk, gently stoned off a few puffs of weed, when he felt a shadow pass over his skin. His vision narrowed, the edges vignetting further and further in black. Budline stood up and shuffled to the bathroom, where he tried to catch half a breath. His heart hammered fast, as if it had absorbed a shot of adrenaline.

He staggered back to the living room and collapsed on the couch. “Guys,” Budline murmured to his two friends, who looked up from the board game. “I think there’s something wrong with me.” The left side of his body felt numb and disconnected. The 22-year-old stared at his hands. They were shaking.

Was it a stroke? Or was it his heart?

He can’t remember who called 911, or how long it took for the ambulance to arrive. By the time he saw the red and white lights strobing through the window, the pain had faded from a heart-straining nightmare into halting, choked-up anxiety. The paramedics gave him the once-over, and agreed on the conclusion: just a panic attack, one that Budline, now 24, estimates lasted about three minutes. “Beyond that, they didn’t really tell me shit,” he adds.

The conversation around mental health care is expanding in the U.S., whether because of TV shows, memes or the elevation of self-care. But on the whole, there remain stigmas around pursuing psychiatric help, problems in how people can access mental healthcare and too many medical practitioners who are flat-out bad at giving feedback about people’s mental-health concerns. Despite more scientific knowledge and pharmaceutical innovation than ever, experts say that Americans’ mental health seems to be getting worse in the last two decades, with more suicides and emergencies despite so many advancements in treating other physical medical crises.

The crisis plays out in emergency rooms all over the country for healthy people who get ambushed by a debilitating storm of physical symptoms. Many are bewildered to hear that paramedics and ER doctors can’t quickly fix them. Instead, they’re left wondering how to unpack a lifetime of stress and anxiety that has weakened the body from the brain down, unbeknownst to them.

An in-depth 2016 report found that around 18 percent of American adults experience a mental disorder in their lifetime, and one in eight ER visits are attributed to a mental or substance abuse emergency. Researchers found a significant increase in mental-health ER visits between 2006 and 2013, most of it attributed to stress and anxiety disorders rather than substance use or psychosis-related conditions. And of the various mental disorders that can suddenly land someone in an ER, a panic attack is perhaps the most common. A 2016 survey of more than 140,000 people around the world found that 13 percent of respondents had a panic attack in their lifetime (a smaller survey of Americans in 2006 found a higher rate, with 22 percent of respondents having had a panic attack).

“Very often, people aren’t aware of the connection between mental and physical symptoms, but the stress of life and our emotional makeup, plus the challenges to that makeup, lead to every symptom under the sun. Headache, chest pain, shortness of breath, vomiting, feeling light-headed, having an awful stomachache,” says Marc Futernick, medical director of emergency medicine at Los Angeles’ California Hospital Medical Center. “For perspective, a lot of people come into the ER with chest pain. About a third of those people have coronary artery disease. Maybe 5 percent are having a heart attack. For everyone else, the real disease can be a needle in a haystack.”

The aftermath of an ER visit can be just as dispiriting as the time within one. If they’re lucky, the patient is put on a path to access psychiatric treatment, medication and follow-up care in a streamlined, convenient way. But in many hospitals, they’re simply discharged with a handful of anti-anxiety pills and a vague recommendation to seek out a mental health professional. The response is so underwhelming at times that some people walk out of the ER with nothing but the feeling that they were stupid to waste an emergency doctor’s time.

Two and a half years ago, Jordan Overson was in Sand Hollow State Park in Utah, camping with a small group of friends near the glimmering reservoir and red-rock formations, when she felt a swell of nausea rocking her insides. Then came a vice-like tightening in her chest, and the sensation of her throat closing up. Sweat dampened her shirt as she tried to manage the crush of pain. Next came the vomit, lurching forward in sharp, painful bursts.

Like Budline, Overson didn’t have much of a medical history or reason to fall ill, but here she was, curled up, shaking in tears and out of breath while her friends looked on. An emergency call brought an ambulance, which shuttled her to a hospital in the nearby city of St. George. “I really wanted there to be something actually wrong with me, and for them to say it was in my head… it was hard,” says Overson, now 23. “The ER did a good job, made me feel validated in my symptoms, but then there was no real follow-up. They simply told me, ‘We think you were having a panic attack,’ but didn’t give any kind of education on what that is and what it meant.

Overson went on an internet research binge to find out more, but nothing prepared her for the panic attacks that followed — almost twice a month for a year after the first incident, she says. While in theory she was more prepared for them, in reality each new panic attack felt as pressing of a physical emergency as the first one. She went to multiple ERs, all around her hometown of Salt Lake City, and found an alarming range of outcomes. “Some refused to give me any Ativan [anti-anxiety medication], they wouldn’t let me talk to anyone, just had a social worker tell me I need to see a therapist. I’ve been discharged from the ER without even a workup or anything,” she says. “These panic attacks were literally ruining my life, and I felt so dumb because I was like, ‘This is all in my head, so I can control it, can’t I?’”

Regardless of the diagnosis, ER visits for mental health rapidly take up time and staff attention, impacting care for patients with more immediate physical medicine needs. Mental health patients in the ER are more than twice as likely to result in hospital admission compared to ER visits that don’t involve mental disorders or substance use. A review of mental health cases in ERs across the U.S. concluded that these visits are “potentially avoidable” if patients are properly managed in the outpatient process, and ideally “should be rare.”

“Managing mental health care is one of the greatest challenges in emergency medicine today across the nation. We in the ER don’t have the resources for that patient population to get ongoing care,” Futernick says. “If we had a better way of preventing the progression from stress to something like a panic attack, that would be fabulous. I don’t see that happening sometime soon, so we at least need to improve the backend so a mental health patient isn’t in our ER for 20, 40, 60 hours.”

The protocol in the average ER is to always rule out the most serious, immediate medical conditions first, adds Reef Karim, a therapist in L.A. with extensive experience as a psychiatric consult for major hospitals. This protocol might start with an EKG to investigate the heart, plus a lab test of cardiac enzymes if the patient has certain risk factors. The problems usually arise after the checklist lands at low-priority mental health issues, he notes. “A good hospital that’s well-versed in mental health treatment will have a psych consult. That’s a psychiatrist who goes to see the patient if they’re in the ER. They’ll go see the patient and say, ‘Okay, I want to set you up in our anxiety disorder clinic, and we’re making you an appointment where you’ll see a doctor and also a therapist,’” Karim explains. “The not-great will maybe give a document with three numbers for outpatient clinics. The worst will just give some Xanax and send you out the door.”

Of course, many hospitals don’t have a psych consult or mental-health team on hand in the ER — even if they’re a large medical center in a densely populated urban area, as Overson experienced in Salt Lake City. Meanwhile, the average ER doctor can only do so much while juggling other patients who are bleeding or passing out. “The first step is differentiating physical health and mental health in that emergency, and I’m sure ER doctors wish more people could make that differentiation, because it’s not their specialty,” Karim says. “I’m sure there are some great ER doctors who have seen mental disorders and can genuinely help, but it’s really not what they were trained to handle.”

Americans are prone to the idea that mental health and physical health are two distinct halves, rather than a muddle of genetics and lifestyle factors that can intertwine and birth psychosomatic disorders, or physical symptoms that are caused or worsened by mental factors. That’s why experts emphasize the urgency of getting a patient on the right treatment path if they have a mental emergency. Even a well-intentioned outpatient process can mire someone in a long, winding, frustrating journey to the correct solution.

Budline, for instance, was left with zero answers after his time in the ambulance. Was it the pot? His appetite for Adderall to help him in the first year of law school? Or something more insidious? He wasn’t sure, and the paramedics didn’t ask him any questions. But about five days later, while sitting on a couch at his dad’s house in mellow Allentown, Pennsylvania, he realized that he had fallen into a precipitous depression — an unexplainable, crushing sadness that scared him.

He saw his primary care physician the next day. The solution, gleaned after 10 minutes of discussion, was a prescription for the antidepressant Zoloft. The prospect of popping a pill to avoid the low made Budline optimistic. Then, a few weeks in, while laying in bed at night, he scared himself again. “I had these vivid thoughts of putting a .44 pistol in my mouth and blowing my brains out,” he explains. “It just went on and on. I didn’t know, at the time, that suicidal ideation was a serious side effect of the medication.”

Then he went through a rough patch with his first psychiatrist, who deemed him bipolar even though the treatment didn’t seem to fit. Finally, in working with another psychiatrist and a therapist last year, he learned that his panic attack wasn’t merely the culmination of general stress, but a trigger for an obsessive-compulsive disorder (in which Budline fixates on irrational, sometimes violent or just strange thoughts) and fluctuating depression.

His doctors thought the Adderall addiction encouraged this development, but his therapist also helped unpack the trauma he experienced in a college relationship with a girl who cheated on him. “After graduation, I made a decision to go back to her, which was the wrong choice. I think I was just trying to cover up the pain,” he admits. “My psychiatrist would always say, ‘There’s something going on that you’re bottling up and not telling me.’ I guess I knew I was hiding that factor, but I was in denial because I didn’t want to go through a breakup again.”

Like Budline, Overson never considered herself a particularly stressed-out person, but her frequent panic attacks pushed her to find a long-term solution. She’s cycled through a dozen specialists since then, finally discovering that her use of the skincare medication Accutane, which can cause a host of physical and mental side effects, might have sprouted the early roots of her panic disorder. Now working as a registered nurse, Overson sees herself as one of the lucky ones, given that delays and frustration with doctors often push away those who have less cash and time to spare. “Even something as basic as getting a psychiatrist and a therapist takes forever. I’m privileged in the sense that I have great health insurance. And I’m a nurse, so I know where to go and I know what to do,” she says. “Most of the population wouldn’t even know where to start.”

What will it take to change that?

One massive shift would be an investment in teaching people about mental health and mindfulness from a young age. Too often it’s a hospital giving some form of this education after an emergency rather than before it, when that information may have helped stop a buildup of subconscious stress. Karim says a genuine effort will have to be visible in schools, on social media, in PSAs and beyond, given that it’s so easy for people to simply forget about managing their mental health until the point when they’re incapacitated by symptoms.

“It would have helped to hear about this in middle or even elementary school because people go through life hearing depression and anxiety and they think, Oh that’s not gonna be me,” Budline adds. “But the truth of the matter is, now that I look into it, just about every one of my friends have been on the verge of considering suicide at one point. What does that say?”

And that reform needs to touch the entire medical infrastructure as well. In addition to a lack of fast, convenient mental-health clinics, there’s still a problem with patients feeling shame or disappointment from doctors who don’t seem to believe or take their psychosomatic symptoms seriously, Karim says. Futernick believes that patients could see better care if more ER doctors were empowered to handle basic psychiatric cases, including people who are symptomatic because they’ve run out of their usual medication. A solid psychiatric backup team and more individual training with prescribing psychiatric medications could be a win-win for doctor and patient alike, he says.

Realistically, these expectations are tempered by more foundational flaws. Case in point: The difference in access to healthcare Futernick’s noticed when working in wealthy West L.A. versus his current position in Downtown L.A., which courts poorer patients from East and South L.A. who are on the widely criticized state Medi-Cal insurance program. “It’s absolutely not available, not easy to obtain, and I’m not just talking mental health care, I’m talking about health care, whether it’s for their diabetes or cancer or bipolar disorder,” he says.

Talking about mental health makes Futernick remember a lesson he learned during his rookie residency years. One of his attending doctors asked him a simple question: “If you’re discharging a 20-year-old with chest pain who probably was having a panic attack, what’s she most likely to die of in the next 30 days?”

His mind ran through the simple answers, like a blood clot, a heart attack or some unusual cardiovascular shock that strikes young patients. But Futernick was way off-the-mark. Given that the patient was so stressed and anguished that they felt serious chest pain, the likeliest cause of death, his mentor said, is suicide.

The lesson stuck with him. A mental-health emergency that lands someone in the ER, hurting and confused, may just be in their head. But the actual outcome once they step out the doors can be as fatal as anything else.