A family brings their daughter to the emergency room at midnight because she has been cutting herself and talking about wanting to die. They sit in the waiting room among people with physical ailments, their daughter's distress visible but her wounds invisible, waiting hours to be seen. When finally assessed, she is placed on a stretcher in a hallway because there are no psychiatric beds available. She waits there for two days, receiving minimal treatment, her parents taking turns sitting with her, everyone wondering whether this is helping or harming. A man in the grip of psychosis is brought to the emergency room by police, combative and frightened, unable to understand where he is or why. The emergency room is loud and bright, the opposite of what his overwhelmed mind needs, and his agitation increases with every hour. A woman arrives seeking help for suicidal thoughts, hoping for connection and care, and finds an overworked system that processes her like a problem to be managed rather than a person to be helped. A physician works the overnight psychiatric emergency shift, seeing patient after patient in a space designed for medical emergencies, not psychiatric care, making decisions about who needs hospitalization when there are no beds, wondering how to provide decent care in indecent conditions. Psychiatric emergency services represent the collision between psychiatric crisis and medical systems not designed for it, providing essential access while often failing to provide appropriate care.
The Case for Specialized Psychiatric Emergency Services
Advocates for specialized services argue that psychiatric emergencies require dedicated infrastructure separate from medical emergency departments. From this view, psychiatric emergencies deserve psychiatric environments.
Medical emergency departments are poorly suited for psychiatric emergencies. The noise, activity, and medical focus of emergency rooms can worsen psychiatric symptoms. People in psychiatric crisis need calm environments and psychiatric expertise, not chaotic settings designed for heart attacks and broken bones.
Psychiatric emergency services can be designed for their purpose. Quiet spaces, trained staff, appropriate security, and therapeutic environment can be created when psychiatric emergency is separated from medical emergency. Dedicated psychiatric emergency services provide better care.
Wait times and boarding reflect inadequate psychiatric emergency capacity. If psychiatric emergencies had dedicated resources rather than competing for medical emergency resources, care would improve. Investment in specialized psychiatric emergency infrastructure is needed.
From this perspective, improving psychiatric emergency care requires: dedicated psychiatric emergency departments or units; staffing with psychiatric expertise; environments designed for psychiatric crisis; capacity adequate to meet demand; and recognition that psychiatric emergencies need psychiatric response.
The Case for Emergency Department Integration
Others argue that integrating psychiatric emergency services within medical emergency departments ensures comprehensive assessment and maintains access. From this view, separation may create problems.
Psychiatric presentations often have medical components. Substance intoxication, delirium, and medical conditions presenting as psychiatric symptoms require medical assessment. Separating psychiatric from medical emergency may miss dangerous physical conditions.
Emergency departments are already built and staffed. Creating parallel psychiatric emergency infrastructure requires substantial investment that may not be available. Improving psychiatric care within existing emergency departments may be more achievable.
Separate psychiatric emergency services may create access barriers. If psychiatric emergency requires going somewhere different than medical emergency, some people may not know where to go. Emergency departments provide universal access point that specialized services may not match.
From this perspective, improving psychiatric emergency care requires: psychiatric consultation available in all emergency departments; emergency department environments adapted for psychiatric needs where feasible; training for emergency staff in psychiatric assessment and care; and integration rather than separation of psychiatric and medical emergency.
The Boarding Crisis
Psychiatric patients often wait extended periods in emergency departments, a phenomenon called boarding.
From one view, boarding is unacceptable and must be eliminated. No one should wait days in emergency rooms for appropriate psychiatric placement. Whatever investment is needed to end boarding should be made. Boarding harms patients and constitutes system failure.
From another view, boarding reflects systemic problems that cannot be solved within emergency departments. Insufficient inpatient beds, inadequate community alternatives, and fragmented systems all contribute. Ending boarding requires addressing root causes, not just emergency department changes.
How boarding is addressed shapes psychiatric emergency experience.
The Medical Clearance Burden
Medical clearance before psychiatric admission often extends emergency department stays.
From one perspective, medical clearance ensures safety. Psychiatric symptoms can result from medical conditions. Ruling out medical causes before psychiatric treatment protects patients. Medical clearance should be thorough.
From another perspective, excessive medical clearance testing delays psychiatric care. Routine batteries of tests may not be necessary for every patient. Streamlined medical clearance protocols would reduce boarding without compromising safety.
What medical clearance requires shapes emergency department length of stay.
The Security and Restraint Questions
Managing safety in psychiatric emergency raises concerns about security and restraint.
From one view, security measures including restraints may be necessary for safety. People in psychiatric emergency are sometimes dangerous to themselves or others. Appropriate security protects everyone. Safety must come first.
From another view, restraint is traumatic and should be minimized. De-escalation should be primary approach. Environments and approaches that reduce need for restraint should be standard. Restraint is failure, not success.
How security and restraint are approached shapes the psychiatric emergency experience.
The Staffing Challenge
Psychiatric emergency requires specialized staffing that may not be available.
From one perspective, psychiatric expertise should be present in emergency departments around the clock. Psychiatrists, psychiatric nurses, and mental health professionals should be emergency department staff, not consultants called when needed.
From another perspective, staffing every emergency department with psychiatric specialists is not feasible. Consultation models, telepsychiatry, and training for emergency staff may be more achievable than embedded specialist staffing.
How psychiatric expertise is made available in emergency departments shapes care quality.
The Triage Challenge
Triaging psychiatric emergencies within emergency department systems raises questions.
From one view, psychiatric emergencies should be triaged based on psychiatric urgency, not medical urgency. Someone in severe psychiatric crisis may not register as urgent on medical triage scales. Psychiatric-specific triage protocols are needed.
From another view, psychiatric patients should be triaged within the same system as other patients. Separate psychiatric triage may marginalize psychiatric emergencies. Integration requires consistent triage.
How psychiatric emergencies are triaged shapes wait times and prioritization.
The Diversion Alternatives
Crisis alternatives may divert some psychiatric presentations away from emergency departments.
From one perspective, diversion should be prioritized. Crisis stabilization units, mobile crisis teams, and crisis receiving centers can serve many people who currently go to emergency departments. Building alternatives reduces emergency department burden while providing more appropriate care.
From another perspective, alternatives cannot serve everyone. Some psychiatric emergencies require emergency department resources. Diversion should complement, not replace, emergency department psychiatric capacity.
What role alternatives play in psychiatric emergency response shapes system design.
The Substance Use Intersection
Substance use often accompanies psychiatric emergency presentations.
From one view, integrated response to psychiatric and substance use emergencies is essential. Many people present with both. Staff need expertise in both. Services should be designed for co-occurring presentations.
From another view, medical stability regarding substances must come first. Psychiatric assessment during intoxication or withdrawal may not be valid. Sequential approach addressing substance state before psychiatric assessment may be appropriate.
How substance use is addressed in psychiatric emergency shapes care.
The Frequent User Question
Some individuals present repeatedly to psychiatric emergency services.
From one perspective, frequent use indicates system failure. If community services were adequate, people would not need emergency services repeatedly. Frequent users should be priority for intensive community support that reduces emergency needs.
From another perspective, some individuals have conditions that produce recurrent crises. Frequent use may be appropriate for their needs. Not all frequent use represents system failure.
How frequent psychiatric emergency use is understood shapes response.
The Canadian Context
Canadian psychiatric emergency services exist primarily within medical emergency departments, with significant variation in psychiatric staffing, environment, and capacity. Wait times and boarding are common problems. Some jurisdictions have developed psychiatric emergency alternatives, but most emergency psychiatric care occurs in medical settings.
From one perspective, Canada should invest in dedicated psychiatric emergency infrastructure to provide appropriate care.
From another perspective, improving psychiatric care within existing emergency departments may be more achievable.
How Canada approaches psychiatric emergency services shapes care for those in crisis.
The Question
If psychiatric emergencies are among the most distressing experiences people face, if emergency departments are poorly designed for psychiatric crisis, if people wait days in hallways for beds that do not exist, if the environments meant to help can make things worse - why do we continue to manage psychiatric emergencies in settings not designed for them? When someone in psychiatric crisis spends days on a stretcher receiving little treatment because the system has no better option, is that emergency care or emergency neglect? When we know what psychiatric emergency services should look like but do not build them, what does that reveal about how we value psychiatric emergencies? When the emergency room becomes holding pen rather than treatment setting, what has emergency care become? And when someone leaves psychiatric emergency worse than they arrived because the experience itself was harmful, what does that say about our emergency response?