The primary goal of any emergency service is the timely rendering of assessment and treatment that is appropriate relative to the presenting acuity. When patients call an ambulance or arrive at an emergency department (ED), the primary outcome measure for them is how quickly they are evaluated and their suffering relieved. Mental health patients, due to acute psychotic or mood symptoms, or simply grossly mismatched needs and resources, are especially affected by long waiting times (3). In many locations, lack of mental health specialists on-site may lead to hours of waiting or to suboptimal assessment and treatment by nonpsychiatric medical professionals. Many persons in mental health crisis leave before assessment, unable to handle long waits in chaotic environments.

Traditionally, patients can come to the attention of the psychiatric emergency department only if they bring themselves or rise to the level of imminent dangerousness and are brought in involuntarily. This paradigm leaves out the mental health patients in crisis who cannot, or will not, access psychiatric emergency services prior to advancing to this level of acuity.

To deal more proactively and preventively with emergencies in the making, psychiatric mobile teams have been created for outreach in the community. This outreach must extend to any location: homes, shelters, the streets, and, for children, the schools. Remote access can also be achieved by efficient use of crisis hotlines and telemedicine tied closely to the emergency system. Ideally, a comprehensive psychiatric emergency program has multiple access points, including mobile crisis teams, crisis hotlines, crisis residential units, walk-in clinics, and the primary emergency department.

The term least restrictive is meant to refer to interventions that are as noncoercive as possible. The PES is often the place to look for the latest innovations of this sort. PES personnel are acutely aware of the fact that their coercive interventions, including seclusion, restraint, forced medication, and forced hospitalization, have profound effects on patients’ perceptions of the service. As described in a variety of surveys (4,5), the more coercive the intervention used, the more negative the patient experience and the more impaired the patient’s trust and willingness to engage with the local mental health system. A PES should be designed not only to contain chaos and violence and promote a collaborative approach to de-escalation, but also to
engage the individual or family in the idea of continuing treatment.

The term least restrictive is problematic when its positive connotations are used as a subterfuge for being unwilling to provide the more restrictive care that an individual may need. Hospitalization, for example, can be very coercive and expensive, and some practitioners may be afraid to recommend it, yet it may be the treatment of choice for an individual who is extremely unsafe, unwell, and unengaged.

With certain notable exceptions, most mentally ill patients in crisis want the same things that any emergency department visitor wants: to be evaluated in a timely manner and obtain mental and physical relief and, if possible, to avoid hospitalization. Whether being treated for a myocardial infarction or major depression, most patients are hoping to receive definitive treatment in the emergency room and to be able to return home. Often, only a brief stay is required. Thus, modern PES environments frequently use extended observation in order to treat consumers in the emergency department as a cost-effective alternative to hospitalization.

PES staff should be prepared to provide definitive treatment if possible, and not defer or triage problems to an outpatient appointment in the future (6,7). They should be capable of assessment, definitive diagnosis, and the application of an array of interventions, including medication, brief psychotherapy, and conjoint counseling. Desired results of definitive treatment include restoring patients’ hope that they will get better mentally and physically, as well as decreasing the time and money required to diminish presenting symptoms and suffering.

Increasingly, collaboration is being recognized as a crucial ingredient of optimal care. Patients and families should be offered choices with regard to treatment, and they should be included in discharge planning. This accomplishes the goal of decreasing intangible costs such as the impoverished quality of life of mentally ill persons and their families struggling to take care of them. In a comprehensive psychiatric emergency system (8), patients may choose less restrictive alternatives to hospitalization, including crisis residential treatment, in-home treatment by a mobile crisis outreach team, or an outpatient crisis clinic.

Above all, the PES must be a place in which patients can expect to be treated with dignity and respect. This means placing top priorities on the safety of staff, patients, and family and, as in other medical disciplines, diminishing suffering as quickly as possible. To this end, PES leadership should provide training for all in verbal de-escalation and psychological first aid, and nurture staff’s psychological well-being so it has emotional reserves to share with consumers. They should also cultivate a program philosophy that noncoercive measures are well worth the time and effort they may require. Placing a priority on safety also means having a strong security staff, but they too are most effective when they feel themselves to be part of the team, are adept at talking to people, and use restraint and seclusion only when ordered as an absolute last resort.

The PES sits in a central position within the mental health care system. Patients too frequently use the emergency room as their outpatient clinic, and patients lost to the outpatient system often end up “appearing” again, now in crisis, at the PES. Small perturbations in the community system (such as a new influx of potent street drugs or a closing of inpatient hospital beds) are reflected by increased utilization of the emergency department. Also, the PES is often the primary location where all psychiatric emergency patients are brought initially. This places the PES in a gatekeeper role.

A gatekeeper is defined as a supervisor or guard who tends a gate, or an individual or group that controls access to somebody or something (9). Control in this manner is frequently misinterpreted as the emergency psychiatrist having the job of denying hospitalization to reduce costs. Although appropriate utilization of resources is important, the negative characterization is usually far from the truth. The PES psychiatrist is entrusted to ensure that each patient is assessed, treated, and referred to the most appropriate level of care according to accepted standards (10,11).

In addition to preventing overutilization of high-end services, the PES staff are also increasingly responsible for jail diversion—creating a welcoming environment to police and patients so that mentally ill patients who have run afoul of the law, usually by committing misdemeanors, receive treatment instead of punishment.

PES staff are also gatekeepers to the outpatient treatment system, sending only those persons requiring outpatient treatment to the community mental health system, and correctly referring patients to the medical and/or substance abuse systems when the psychiatric illness is secondary to these factors. Yet services for dual-diagnosis patients and those with chronic pain are often lacking in the greater health care sector. Many systems even lack basic outpatient services. For example, clinic networks that accept only those patients with major mental illnesses and exclude anxiety and personality disorders force a PES practitioner to choose between either standing by helplessly until an individual deteriorates enough to qualify for referral or building up an unwieldy ambulatory care “practice” that distracts attention from acute care.

The last gatekeeper function is indirect: decompression of urban medical emergency departments. PES units are regional specialty emergency centers intended to enhance and strengthen the ED community, analogous to the role of the level 1 trauma center. Unfortunately, medical and psychiatric emergency departments are reporting record numbers of individuals seeking psychiatric care. Overcrowding of emergency departments with mental health cases is currently a national crisis (12).

Interestingly, in contrast to PES psychiatrists, concerns have been raised about the possibility of ED physicians overadmitting psychiatric patients to inpatient hospitals to expedite ED throughput and reduce malpractice risk. In reality, the psychiatric gatekeeper role has often been foisted upon these medical emergency physicians, and they are simply using their best judgment without adequate access to psychiatric consultation.

Every mental health care system tracks recidivism, or the tendency to relapse and present again in psychiatric crisis. One important key to decreasing recidivism for mentally ill patients is to eliminate the idea behind the word discharge and to design programs that provide “wraparound” services (13). Also referred to as “glue,” these ser-vices offer support and assistance with community reintegration and linkage to ongoing outpatient care for patients released from a PES, inpatient psychiatric service, or a jail. Modern comprehensive psychiatric emergency programs have found that their components and follow-up services such as mobile crisis teams, crisis stabilization and residential units, outpatient crisis clinics, and crisis hotlines are especially helpful for individuals in crisis who were appropriately diverted from hospitalization to a lower level of care but remain at risk for further decompensation. Continuity of care is frequently a challenge because the PES often operates in isolation from outpatient systems, and many psychiatric emergencies occur after hours and on weekends.

One of the greatest challenges in continuity of care is working with individuals who are sometimes referred to pejoratively as “frequent flyers.” In reality, it is better to think of them as people maladaptively trying to survive in a badly fractured system. They require PES staff to take the long view and be prepared to offer repeated episodes of short-term case support until they are productively engaged in more traditional programs.

As mentioned earlier, the modern PES is actively engaged in various kinds of community outreach. Mobile teams provide assessment, crisis intervention, and short-term case management in the schools, homes, shelters, jails, and street corners. They meet police on bridges to help potential jumpers. PES educators speak about crisis intervention to National Alliance on Mental Illness (NAMI) consumers and families, school principals and counselors, law enforcement officials, and civic leaders. Topics include mental illness, substance abuse, noncoercive de-escalation, medication, creative access to community mental health resources, early assessment, and collaborative intervention with potentially high-risk individuals before they escalate to the point of requiring coercive police involvement.

The PES should be not only a safety net for the mental health system but also an active participant in the governmental safety net, taking its place beside police, fire departments, and the emergency medical system. In areas where the community mental health centers have long waiting lists, the PES can provide services when those on the waiting list start to decompensate. In mass disasters, the PES can partner closely with the
Red Cross and take a leadership role in coordinating the array of a community’s mental health services, public and private, that can surface and risk working at cross purposes. As a nonproprietary, governmentally sponsored agency specializing in emergency mental health, the PES has the potential for promoting collaboration between organizations that might otherwise be in competition with one another. Ideally, the bridges that are built during the disaster preparedness activities can improve the partnerships as disparate groups conduct their nondisaster business as usual.

Another obvious community benefit is finding cost efficiencies. By providing alternatives to hospitalization and jail, a PES can offset more costly and restrictive interventions. It can also offset other tangible costs of court commitment, involuntary transport costs, and, at times, of calling out SWAT teams. PES leaders often have a vast fund of knowledge about various government financial programs, grant offerings, and obscure funding streams that can make a significant difference in the levels of service that can be made available.

Training opportunities abound in psychiatric emergency programs. In addition to psychiatric residents, psychology interns, nursing and medical students, and social workers, one sees pharmacy students, pastoral counselors, EMTs, and police. The Crisis Intervention Team (CIT) model for police working with those members of the public with mental health issues came out of a partnership between law enforcement and the PES community (14). Police officers take classes in emergency mental health intervention, meet mental health consumers in recovery, and shadow PES staff to learn more about noncoercive techniques. PES staff sometimes ride along with police officers to learn more about things from the law enforcement perspective.

Optimal training in the PES requires skilled professors and supervisors with hands-on experience and theoretical knowledge. A comprehensive, biopsychosocial model is the most helpful approach, meaning that trainees must become familiar with medical issues, descriptive diagnoses, medications, nonverbal and behavioral techniques, and psychotherapeutic strategies of engagement. Cognitive-behavioral and dialectical behavioral therapies are critical in the handling of personality disorder–related issues and acute adjustment disorders. From an analytic perspective, PES staff should understand and be capable of handling resistance and defenses. Family and systems perspectives are also integral to performing family and couples interventions.

Brasch et al. (15) presented a model curriculum for psychiatric residents developed by the American Association for Emergency Psychiatry (AAEP) education committee. The authors made recommendations regarding training setting, timing and length of training experience, faculty and supervision of training experience, curriculum content, and program evaluation. This curriculum is further discussed by one of the curriculum’s authors in Chapter 42. Research opportunities in the PES are plentiful, but difficult to implement. Clinical investigators are frequently overwhelmed with the demands of providing care around the clock. Budgets for administrative assistants are usually quite slim. Agitated or aggressive patients do not make good candidates for studies requiring informed consents. Electronic medical records with relational databases are just starting to appear or are primarily used as administrative tools to complete documentation and service contact requirements.

Research has also been difficult because the definition of what constitutes a PES varies, making comparing data between services difficult. Further, most studies are descriptive, without empirical analysis. They have poor generalizability due to small or otherwise restricted samples, weak statistical analyses, and poor standardization of evaluation (16). Cost-benefit analyses and the effects of variations within administrative and clinical structure have not been studied with regard to the effect on outcomes.

The Psychiatric Emergency Research Coll-aboration (PERC) was created in 2005 and now includes nine sites in the United States and one in Europe. The PERC studies issues of insurance status, management and treatment, disposition, presenting complaints, levels of agitation/aggression, mental status elements, and suicidality. The PERC also studies medical comorbidity, diagnostic/laboratory testing ordered, toxicology results, psychiatric medications administered, use of restraints and seclusion, forced medications, and turnaround times (17).

Conclusive research demonstrating that the PES model has outcomes that are efficacious, cost-effective, accessible, and culturally competent is eagerly awaited. In addition, research is still needed to show the PES’s impact on homelessness, recidivism, and substance abuse relapse. Research in emergency psychiatry is discussed more completely in Chapter 44.