TUCSON, Ariz. — On a spring afternoon, about a half dozen children and teens hung out in the sunny common room of Pima County’s Crisis Response Center in Tucson. Beyond the pastel-painted room stretched a long, wide hall where partitions separated individual beds, many left unmade with rumpled sheets. Wearing scrubs, the kids sat in rocking chairs, watched TV, talked and laughed. A pair of teen girls played a card game.
Outside the large windows was a walled patio where they could play cornhole or have water balloon fights in the open air. Chalk drawings depicting stars and flowers covered the patio walls.
On the other side of the building, adults in crisis rested in recliner chairs in a more subdued setting. Some patients slept, others watched TV. Like the kids, they could opt to attend daily group sessions on emotional processing, coping skills, and art expression. And like the kids, they received three meals and two snacks per day, with additional snacks available by request anytime. Psychiatric staff would periodically stop by to check their progress and help them make plans to continue treatment at home. And peer support specialists (staff members in recovery from addiction or mental illness themselves) would sit with them to share their own stories of struggle and healing, teach them coping skills, and offer them hope.
Jenna Possidento, who has survived anxiety, depression, and a suicide attempt, now manages the team of peer specialists. When she describes the center, the word she most often uses is “comfort.” The fundamental question her team asks patients, she said, is, “What is it that you need from us to feel better today?”
In most other parts of the country, people seeking care during a mental health crisis would probably land in a much different place. It would be noisy, busy, and chaotic. Food and comfort would be scarce. It would be jammed with beeping medical devices, strained by long wait times, ruled by restrictive protocols, and staffed by few if any mental health specialists.
That place would be the emergency room.
Through decades of twists and turns in public policy and health care financing — alongside national neglect of mental health — the emergency room has become America’s default front door to psychiatric crisis care. People in the grip of severe anxiety, depression, or psychosis need to reach acute outpatient or inpatient care, and the emergency room is the portal to get there. Yet emergency rooms are rarely designed or equipped to provide optimal care during mental health emergencies. And the consequences of this system, which were always problematic, are now nearing catastrophic.
“It’s really at a horrible breaking point,” said Gail D’Onofrio, a professor of emergency medicine, addiction, and public health at Yale University and an attending emergency physician at Yale New Haven Hospital. As the place of last resort, “We keep our arms open, we are there for everyone, but we are being overwhelmed by mental health issues, and it’s not something that I can fix as an emergency physician.”
Patient advocates and emergency care providers alike are sounding the alarm about the gaps between emergency rooms’ capabilities and the mental health needs they’re expected to meet, especially as surging mental illness and the Covid-19 pandemic have strained health care systems in recent years. Yet as national awareness of mental illness rises and innovative care models emerge, many advocates now see a rare opportunity to remake mental health crisis care for the better.
Nearly 6 million adults went to the emergency room for mental health emergencies in 2021, the Centers for Disease Control and Prevention reports — up 1 million since 2017. Among children and young adults, emergency room mental-health visits increased an average of 8% per year in the decade from 2011-2020, a study published in the Journal of the American Medical Association estimates.
This means that ER staff are overwhelmed as facilities overflow, with patients housed in waiting rooms and hallways while experiencing terrifying symptoms. The result is cost overruns for hospitals and poor outcomes for patients, some of whom get stuck in emergency rooms for days, weeks, or even months.
Thomas, a software engineer in Cambridge, Mass., who asked to be identified only by his first name, has had this experience more times than he can count. His first came at age 15, when he spiraled into a deep depression and woke up to find three police officers in his bedroom readying to take him to the hospital. Thomas coped with his psychological distress by using alcohol and drugs and cycled in and out of hospitals for years, until he finally got sober and got the right medications for his bipolar disorder at age 21. Over a decade of stability, he built a career, married, and bought a home. But in his early 30s, after a divorce and a move from Connecticut to Massachusetts, he spun into depression again.
When Thomas walked into an emergency room in Cambridge in spring 2023, accompanied by his aunt, he felt suicidal for the first time in his life. He didn’t want to be in an emergency room but knew he needed to be. He felt scared.
Then, “You’ve got to sit in this room, maybe they won’t give you water, maybe you’re not wearing clothes. It’s loud, it’s bright, there’s a lot of noise, there’s other sick people freaking out, and it’s just too much,” he said. Even worse, standard protocols and procedures can often make patients feel like they have a lack of agency, “and now it’s not your choice anymore and you don’t want the help anymore.”
In Cambridge that evening, Thomas first had to tell the intake staff about his troubles in the waiting room, within earshot of other patients. Then he and his aunt waited for four hours before seeing a triage nurse. With all rooms full, a nurse finally placed him on a bed in a hallway around midnight, surrounded by other patients who appeared intoxicated, and asked about his symptoms again. “So it was again talking in front of a bunch of people about how I want to kill myself,” Thomas recalled.
Over the next 16 hours or so, hospital staff assigned a security guard to stand and watch Thomas 24/7 because of his suicidality. A psychiatrist finally arrived around 4 a.m. and asked him to repeat his troubles a third time. He refused, she asked again, and he became angry. After that, a physically imposing male nurse appeared and told Thomas he was being “sectioned,” or committed to treatment without his consent (a standard protocol for patients who may be a danger to themselves or others). The nurse ordered him to change into a gown. “This is terrifying,” Thomas remembers telling the nurse. At about 4 p.m., an ambulance team appeared to take Thomas to another institution, without anyone telling him where he was going.
Emergency rooms simply are not designed to treat mental health crises.
“It’s a great place to be if you’re having a heart attack or if you’re in sepsis,” said Scott Zeller, vice president of acute psychiatry at the health care partnership Vituity and past president of the American Association for Emergency Psychiatry. “If you’re having a psychiatric emergency, it’s claustrophobic, it’s scary, there’s uniformed personnel running around, you can’t get anyone’s attention. It’s not a good place to be when you’re in that level of distress.”
A survey published in 2022 found that more than half of U.S. emergency rooms and general hospitals have no psychiatry services. “So people end up waiting days … and during that time they’re untreated,” said Margie Balfour, chief of quality and clinical innovation at Connections Health Solutions, which runs Tucson’s crisis center. She’s also an associate professor of psychiatry at the University of Arizona. Emergency medicine physicians can address basic psychiatric symptoms (just as a primary care physician can prescribe drugs for anxiety or mild depression) and give medication for agitation or substance use withdrawal, Balfour explained. But for real healing, patients need to be transferred elsewhere, and that wait can be destructively long.
The American College of Emergency Physicians (ACEP) reports that patients with psychiatric needs wait on average three times longer in emergency rooms than those with medical needs. Waiting in the emergency room for an inpatient bed — medical or psychiatric — is called “boarding,” and boarding is one of the most painful symptoms of this strained system for both staff and patients.
In a letter to the White House in 2022, ACEP and more than 30 other medical associations and advocacy groups warned that boarding in hospital emergency departments (EDs) “has become its own public health emergency.” ACEP cites numerous studies showing a link between boarding and an increased risk of illness and death for patients with either physical or mental health emergencies. “When ED beds are already filled with boarded patients,” signers of the White House letter wrote, “other patients are decompensating and, in some cases, dying while in ED waiting rooms during their tenth, eleventh, or even twelfth hour of waiting to be seen by a physician.”
For psychiatric patients, Balfour explained that waiting can worsen a patient’s distress and cause agitation, which, in turn, can lead to violence against emergency room workers. In a 2024 poll of ACEP members, 91% of emergency physicians said they or a colleague were assaulted on the job within the past year. Safety protocols say agitated patients may be forcibly injected with a sedative or restrained and strapped to a gurney. That experience can itself be traumatizing to patients.
The system presents particular problems for children. Joeli Hettler, a physician in the pediatric emergency department at Baystate Health in Springfield, Mass., describes the “moral injury” felt by emergency staff as they care for children in settings where providers are required to follow procedures designed for adults. “Sometimes it’s not only excessive, it can be traumatizing,” she said. “It’s really hard to see a 5-year-old who threw some crayons at a teacher get wanded by a security officer that looks like a policeman.”
Hettler’s emergency department designates certain rooms for psychiatric patients, but medical and psychiatric patients are still in close quarters. If there’s an acute medical situation, such as a resuscitation, staff try to shield children with screens or earphones, Hettler said. “But they know something bad has happened. They see staff members walking out of the room with tears in their eyes, they hear parents crying.”
Similarly, if a child in psychiatric crisis has to be forcibly sedated because they’re acting unsafely, she said, “when our medical kids have to witness something like that, that can be really scary.”
Across the country, boarding can be especially lengthy for children, for whom inpatient placements are scarce. Inpatient facilities often cherry-pick which patients they will take, preferring those who speak English and have robust private insurance and stable housing and declining those who have developmental disabilities or autism or who are transgender, emergency care providers explained. James Bryant, a veteran administrator in emergency nursing across multiple states, said he once had to keep a child with a mental health condition in a North Carolina emergency room for six months and two days.
This kind of lengthy and complex care often costs emergency rooms far more than they can bill for their services. Hettler, who is also an associate professor of emergency medicine at UMass Chan Medical School – Baystate, co-authored a study that mapped the requirements of pediatric mental health care in her emergency room, including staff, equipment, and space. Emergency departments are typically reimbursed only for the initial medical evaluation part of a psychiatric visit, which takes about an hour, Hettler said. But the researchers put the cost of caring for one such patient at $219 per hour, “with most activities offering little to no value to the patient.” Boarding averaged 11.7 hours, for a cost of $2,406, a significant portion of which was for one-on-one sitters to watch patients at all times to ensure their safety.
Emergency physicians point out that some patients in mental health crisis truly do need to be in an emergency room — but only some. Youths who have overdosed, had an emergency medical problem, need care after a sexual assault, or are actively trying to hurt themselves or others “need the 24/7 expertise of an ED,” Hettler said. “If none of those things are true, the ED is the wrong place for them.”
The emergency room is, in a sense, like a sandwich without any bread. People with mental health struggles need care before they reach a crisis, in the form of accessible, affordable care in the community to manage medications and support healthy coping — ideally preventing the crisis in the first place. And they need care after a crisis, to provide inpatient treatment or outpatient support to return to daily living. But in the U.S., only the emergency room is easy to access. Mental health care both before and after crisis is often out of reach.
A large part of the problem, said Ken Duckworth, chief medical officer of the National Alliance on Mental Illness, is that the entire mental health care system is underfunded and under-bedded. Starting in the 1960s and 1970s, states began a decades-long process of “deinstitutionalization,” releasing patients and shutting down state mental health hospitals with a goal to build community mental health centers to care for people closer to home. But the money to build those centers at a national scale never materialized.
A report from the NRI research institute showed that from 1970 to 2018, the number of psychiatric state hospital beds decreased by 90%. The number of inpatient beds in other settings increased over the same time, but more gradually, still leaving a net reduction of 60%.
Advocates argue that even as mental health care has shifted more into the main health care system, it continues to be treated as an afterthought, separate from and second to medicine. The net result is that “people with serious mental illness in many places don’t have a serious home,” said Richard Frank, a senior fellow at the Brookings Institution. “The emergency rooms aren’t the bad guy here. But when you neglect investing in something for 50 years, catch-up is slow and painful.”
These challenges are compounded by the fact that the emergency response system — starting with 911 calls — typically makes armed police officers the first responders to mental health crises, a role for which police are rarely fully equipped or trained. A Washington Post review of all civilians killed by police since 2015 shows that 1 in 5 had a mental illness. Officers may choose to bring a person in crisis to jail or, if they recognize the need for psychiatric care, to an emergency room. But a hospital drop-off can cost an officer hours, and Tucson Police Sgt. Jason Winsky said many police don’t feel it’s what a patient really needs.
“The police community has known for decades that that tool doesn’t work for this population,” Winsky said. “But even here in 2024 it’s still usually the only tool that most cops have across the country.”
Conditions across the country may at last be ripe for change. The psychological strain wrought by Covid-19, along with a series of high-profile police shootings of people in mental health crisis, have pushed mental illness from the shadows into the spotlight of national consciousness. Legislators in Washington, D.C., have launched bipartisan efforts to expand mental health services. Medicaid has created new financial incentives for mobile mental health care.
The biggest lever many advocates see is the national 988 phone number, designed to work like 911 for mental health emergencies, which launched in July 2022. The number received nearly 5 million calls in 2023, answered by a network of local, independent crisis centers. Some of the number’s key features, such as geolocation, are still in development. But advocates see its launch as a watershed opportunity to spotlight the massive scale of unmet mental health need and build a system of care around it.
“It will become rapidly apparent to us what’s become an invisible disaster,” said Joe Parks, medical director of the National Council for Mental Wellbeing. Just as the launch of 911 in 1968 fueled the growth of ambulance services and emergency rooms, Parks expects 988 to drive expansion of the mental health emergency system. “We’re on the cusp of all this changing,” he said. But as the calls come in, “then the question becomes: where do I send all this stuff?”
The answer, mental health advocates say, needs to come from both inside and outside the hospital.
Innovators around the country are introducing layers of services that can treat people across the continuum from mild to severe crisis. Many of these efforts are happening outside the hospital setting, where mobile crisis teams respond instead of (or in tandem with) police to evaluate and assist people in the field, while community mental health centers and crisis “receiving centers” help people stabilize. Chicago’s Treatment Not Trauma program is one model.
As of 2023, the NRI research institute reports that there were nearly 1,800 mobile crisis teams operating across the U.S., with plans for at least 170 more. There were more than 600 crisis receiving and stabilization facilities, with plans for 180 more — though the level of service in different settings varies dramatically. In King County, Washington, where the only mental health crisis facility requires an advance referral, voters recently passed a $1.25 billion property tax to build five walk-in crisis centers.
The Crisis Roadmap, published by the National Council for Mental Wellbeing, also proposes services to prevent a crisis before it even begins — such as community outreach and walk-in access at community mental health clinics — plus care coordination and accessible outpatient care to help keep people healthy after a crisis has passed.
Mobile teams and dedicated mental health centers can provide crisis care at much lower cost than a medical-surgical hospital, Parks pointed out. But unlike “medically necessary” ambulance rides and emergency room visits, which most insurance covers, mobile crisis and crisis receiving services are rarely covered.
At the same time, a growing number of hospitals are finding ways to provide dedicated psychiatric crisis care within their own walls. One model is the EmPATH unit, short for Emergency Psychiatry Assessment, Treatment and Healing. Zeller, of Vituity, helped design the prototype at a hospital in Oakland, Calif., more than a decade ago when he was chief of psychiatric emergency services at Alameda Health System. As a specialist in alleviating agitation and aggression, Zeller wanted to create a soothing space that could help patients stabilize, with the fewest possible constraints on their freedom, and quickly return home.
The design centers on a “milieu room,” an open area where patients rest in recliner chairs, similar to those at the Crisis Response Center in Tucson. They can walk around, play board games, or lean their recliner back and nap. This social interaction supports stabilization. Snacks, beverages, and phone calls are available to patients anytime. Staff can see every patient from the central nurses’ station, eliminating the need for one-to-one sitters.
“We change that environment from one of coercion and oppression to one of a therapeutic alliance,” Zeller said.
An EmPATH unit works closely with its hospital’s emergency room, which should ideally transfer patients in crisis into EmPATH as quickly and smoothly as it might refer a woman in labor to the maternity floor. The units aim to have every patient see a psychiatrist within 60 minutes of arrival, which reduces agitation and allows them to begin medication. Care providers then monitor each patient’s progress and help them make plans to return home with medication and follow-up care — often within 24 hours — or place them into substance abuse or inpatient programs. EmPATH units bill insurance hourly, using the same billing categories that a cardiac observation unit does, with a goal only to break even.
Studies of Zeller’s prototype unit and others modeled on it have shown significant benefits in patient outcomes and cost. In a 2014 study of the original unit, patients boarded an average of 1 hour and 48 minutes, compared to a California average of more than 10 hours. California hospitals at the time were sending most psychiatric emergency patients to inpatient care, but Zeller’s unit sent only 25%. The rest returned home. A more recent study showed suicidal patients receiving care at a University of Iowa EmPATH unit, rather than a regular emergency room, were 60% more likely to participate in follow-up care in the month after discharge.
Centra Lynchburg General Hospital in Virginia opened its EmPATH unit six months ago. James Bryant, vice president of emergency services, said it has transformed his previous experience in emergency nursing. “To see people interacting and laughing and sharing stories is a world of difference from what you see 50 feet down the hall” in the emergency room, he said.
In its first six months, Bryant said the unit has reduced mental health patients’ length of stay by 20%, referrals to the psychiatric inpatient unit by 20%, and the hospital’s sitter cost by at least 20%, equivalent to a savings of $1 million per year.
“As someone who’s done this for 40 years, it’s really the first thing I’ve seen that’s really made a difference,” Bryant said. “I truly believe that this will become a standard.”
In Tucson, the Crisis Response Center is part of a nationally lauded initiative that brings many of these innovations together in one coordinated system.
“What you see now around the country is places that have a crisis line and crisis mobile teams but no crisis center, or they have a center but they don’t have a way to get people there,” said Winsky, who runs the Tucson Police Department’s Mental Health Support Team. “Everyone has components, but very few places have all of them.”
The system arose from historic neglect. In a class-action lawsuit in 1986, an Arizona court ruled that the state and Maricopa County were failing their legal obligations to people with serious mental illness. That lawsuit finally ended with a 2014 settlement that bound the state to provide comprehensive community mental health services.
Balfour, of Connections Health Solutions, said that the state’s crisis system is built on its Medicaid managed care system, with a couple of key innovations. First, all mental health service providers report to a regional behavioral health authority and share the goal to stabilize people in the least restrictive (which is also the least expensive) possible setting — ideally in mobile or community care instead of a hospital or jail. Second, Arizona combines funds from Medicaid and other federal and state sources to pay these organizations based on their capacity, not per service provided. The state’s mental health crisis system is available to all residents, regardless of whether they are insured or what kind of health insurance they have — including people on private insurance whose plans often do not cover mental health crisis care.
Balfour said that 80% of Arizona’s 988 calls are resolved on the hotline. Then 70% of the remainder are resolved in the field by a mobile crisis team, and 60% to 70% of people who need care at a crisis center are ultimately able to go home rather than to inpatient treatment. After departing, only about 1 in 3 people use mental health services again within the following month. At each stage of service, responders try to divert patients from the criminal justice system into the care system.
The Tucson crisis center’s collaboration with police makes it particularly unusual. On an April morning, two officers from the Tucson Police Department’s mental health team set out to serve a court order for a man in his 60s who had stopped his medications and become delusional, making threats against the case managers and fellow residents at his boarding house. The officers found him sitting on a twin-size bed in a back bedroom at the boarding house.
The white-bearded man became upset upon their arrival.
“You coming to put me under arrest?” he asked.
“No, we have a court order to take you to the treatment center,” Officer Joshua Godfrey answered.
“I got a right to remain silent,” the man told him. “You’re acting like a f—ing terrorist.”
“Fair enough,” Godfrey replied, keeping his tone polite.
The man grudgingly rose and packed pill bottles and other belongings in plastic grocery bags, which he hung on the handles of his walker, then shuffled out of the house in slippers. In the back of the police car on the way to the crisis center, he repeated his belief that someone had been beaten to death at the boarding house. He called his sister. “The terrorists come over this morning to grab me,” he told her. “I’m in the backseat of a terrorist mobile. I’m being kidnapped.”
“Where are they taking you?” she asked on speakerphone.
“The Crisis Response Center,” Godfrey explained.
The man’s sister said a prayer to Jesus for his safety and sound mind.
“I love you,” he told her.
“I love you,” she replied.
The crisis center was built with money from a voter-approved bond. It’s open 24/7 and takes anyone, no matter the severity of their crisis or intoxication, even if they may try to hurt themselves or others. In fact, the center’s leaders say they have staff trained in de-escalation and such patients may be less likely to be physically restrained here than in an emergency room. Patients with medical needs can be seen at the hospital next door, then return to the crisis center for psychiatric care.
Before the center opened, Godfrey said, he once waited for seven hours on a 10-hour shift to check a suicidal person into an emergency room. But the crisis center offers police their own private entrance and a swift drop-off process. Godfrey buzzed, and after a few minutes he and the man he’d brought to the center entered. Inside, a staff member asked Godfrey a couple of questions, then asked the man where he lived and how he was.
“Are you hungry or thirsty?” she asked.
“Yes, I am,” he said.
And with that, he was a patient in the center and the police departed.
Winsky, who grew up as the child of a psychologist and a psychiatrist, said this system enables his officers to take hundreds of people per month to the crisis center instead of the emergency room or jail. But for a system like this to work, Winsky said, law enforcement has to be involved in designing the solution from the beginning.
Scaling new models for providing crisis care nationwide is a challenge. Balfour believes the linchpins are in the details: Insurance companies should be mandated to pay for psychiatric crisis care as a matter of parity between physical and mental health. Ambulances must be paid the same to take a patient to a crisis center as to an emergency room. States need to develop the licensing and regulations to support these services. (Connections Health Solutions is expanding its crisis-center model into Washington, Virginia, and Pennsylvania, but Balfour said they need at least a year lead time per state to establish the necessary regulations.)
One day, everyone may know to call 988 rather than 911 for a mental health crisis. And eventually, a nationwide infrastructure of crisis mobile teams may be in place, backed up by numerous on-demand crisis centers. “But that’s not where we are in 2024,” said Winsky.
The real question, say the experts, is whether we are ready to take mental health crises seriously. Parks of the National Council for Mental Wellbeing asked, “If you had people with a broken leg spending a week in the ER because there was no orthopedic bed, how long do you think everybody would put up with that?”
If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.
This story is the sixth and last in a series on the U.S. mental health system, supported by a grant from the NIHCM Foundation. Our financial supporters are not involved in any decisions about our journalism.
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