How Can We Improve Emergency Department Psychiatric Care?

Scott Zeller, MD

Scott Zeller, MD
Chief of Psychiatric Emergency Services for the Alameda Health System

“John,” a 28-year-old man, is brought to a small community hospital emergency department (ED) after difficulty at home; he is at the time of arrival yelling at his mother and pulling painfully at his hair. John’s mother, who lives in the suburbs of a metropolitan area, is employed full-time as a software engineer and is prominent in the local community. Her employer-sponsored health insurance does not include coverage for John, but he does have Medicare.

The ED staffers, who unfortunately have little training in behavioral health care, feel they must immediately put John into restraints. The staffers yell at John to “please be quiet” because “you’re scaring people, people who are here for a real emergency.” Meanwhile, other ED staffers are already on the phone to hospitals within a 100-mile radius, seeking a facility with an inpatient psychiatric bed that will accept John in a transfer. John is forcibly injected with sedating medication putting him into a deep sleep while the transfer is sought. Despite his mother’s presence, the ED has very little to offer John besides this approach, which is their default care for most psychiatric emergencies.

A growing problem
According to Bazelon Center for Mental Health Law, individuals with mental health conditions utilize the emergency department at a higher rate than the general population. As budgets for state and local social services have been reduced and outpatient programs decrease, the number of people presenting at hospital EDs typically increases. For example, psychiatric visits to EDs in Chicago rose 37% over a four-year period ending in 2013, the largest increase coming in the year the city shuttered half of its mental health clinics in a budgetary move.

In its 2014 annual report, the US Commission on Civil Rights made several recommendations regarding how to treat people presenting to hospitals with a mental health condition, including implementing consistent protocols and discharge planning; fostering learning from best practices; and adopting an expanded, uniform definition of “stabilization.” The report further stated that, if these recommendations were implemented, hospital staff and physicians would receive better training and care would improve.

Best practices replace “restrain and sedate”
EDs require physicians to use rapid assessment and decision-making skills. In an outdated paradigm, when faced with a psychiatric emergency, ED staff often resort to a quick infusion of medication and physical restraints. Project BETA (Best practices in Evaluation and Treatment of Agitation), a more modern protocol, provides a more effective course with better outcomes and less need for forcible approaches.

At its core, Project BETA replaces what is often called “restrain and sedate” with algorithms that not only look to enhance staff safety—as two-thirds of staff injuries can occur during “containment”—but also are patient-focused and seek to promote engagement rather than coercion.

Project BETA adopts a three-step approach to stabilize individuals by verbally engaging patients, creating an environment of collaborative treatment, and conducting verbal de-escalation. When successful, the patient becomes invested in his or her own treatment, is more apt to participate and follow-through with discharge instructions, and thus may be less likely to return to the ED. Implementation of Project BETA protocols does not dismiss the use of medication, but rather solicits the input and collaboration of the patient in accepting an agreed-upon course of treatment. Another positive consequence of these guidelines is the increased likelihood that a patient can be successfully transferred to a more appropriate facility, as many hospitals and residential programs will not accept a patient who has been restrained.

Training key to success
When considering initiating Project BETA, it is important not only to invest in training the medical staff who are involved, but also the additional personnel who may engage with people having psychiatric emergencies. Thus, the intake clerk, the security guard, and the custodial staff should understand that psychiatric emergencies are due to illnesses, not character problems. Think of an agitated individual not as an adversary, but as a good person who is having a terrible day and is having the psychiatric equivalent of your worst headache ever—thinking along those lines, who wouldn’t want to help rather than call security to do a ‘takedown’?

An instinctive ability to be comfortable engaging in de-escalation techniques can be helpful, but actually, just about anyone with a true desire can develop these skills. When conducted properly, verbal de-escalation can be effective in five minutes or less. Formal role-playing or on-the-job encounters with non-agitated patients or each other can provide staff with opportunities to learn these skills.

Recently, there has been very positive interest nationwide in adopting newer, more humane, more effective strategies in working with psychiatric emergencies. An unprecedented alliance of consumers, advocates, and multiple disciplines of healthcare providers has joined together to form COPE, the Coalition On Psychiatric Emergencies. The partnership of such organizations as the Depression and Bipolar Support Alliance (DBSA), the National Alliance on Mental Illness (NAMI), the American College of Emergency Physicians (ACEP), the American Psychiatric Association (APA), the Emergency Nurses Association (ENA), and many other major stakeholders seeks to bring everyone to the table to finally improve emergency psychiatric care across our nation. While early in the process, there is plenty of reason for optimism that such solutions may finally be near.

So that you or your loved one might avoid a situation like our hypothetical patient “John,” first research what treatment options might be available in your area before a psychiatric emergency happens. Contact your nearby hospital’s ED and ask them how they handle psychiatric emergencies. Look for online or published reviews on the best hospitals in your area. After all, if you would try to avoid a hospital with a less-than-stellar reputation for treating cardiac emergencies, why should you be less diligent with your mental health?

Your Turn

  • In what ways have you or your loved one been treated well, or poorly, at hospital emergency departments when dealing with a psychiatric emergency?
  • How do you think implementation of a standard protocol like Project BETA would affect the quality of care at EDs?
  • What would you do to improve the availability and quality of care for psychiatric emergencies in your area?


Scott Zeller, MD, is Chief of Psychiatric Emergency Services for the Alameda Health System in Oakland, California, and Past President of the American Association for Emergency Psychiatry. He is the author of numerous scholarly articles and book chapters, lectures internationally as a keynote speaker, and was co-editor of the textbook “Emergency Psychiatry: Principles and Practice”. Dr Zeller directed the Project BETA international best-practice guidelines for agitation in 2012, was the 2013 California Hospital Association’s “Person of the Year,” and was named the 2015 United States National “Doctor of the Year” by the National Council for Behavioral Health.

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Unity Point Health Methodist Hospital in Peoria Illinois has a good program. It is timely to be evaluated, but it takes time for quality care. They have a behavioral health ED that people are able to be seen in for the safety of the patient and the safety of others. Having been a patient there above 20 times, not always willingly, I can say they do the best job they can without forcing restraints. It helps that they know me there, but I've been to other hospitals who do not have this in place and it is utterly terrifying, which is highly unnecessary. I believe the times that I was talked through a situation, I was able to be calmed down within minutes without forced restraints or medications. When I did need medications to calm down, I was part of the decision, not an after thought. I believe the system works, but everyone has to comply and have the training. But, the training man hours is worth it and necessary if things are to improve. Look at Unity Point and you will see.


I know someone who had been off meds and in a downward spiral.  Problems and home and problems at school.  Landed in ED on a 72 hr mental health hold by the police after he had a fight with his dad and held a knife to his own throat.  He wouldn't put the knife down and was subsequently tasered by police. Within 2 hours a call was received at home that patient was being released, there was no problem.  Nevermind they have a charted history of patient, information from police and family. Because the patient was presenting calm (his immediate crisis is over) and talking about graduation and girlfriend, the hospital staff didn't see any real problem.  In fact, they thought he was looking for attention. 

I do believe ED staff are not adequately trained an I also feel that insurance companies are to blame as well.