Bridging the Rift: Tips to Improve the Emergency Medicine and Psychiatric Clinician Relationship

“Emily,” a 14-year-old girl, was arguing with her parents when things spiraled out of control. An honor roll student who had been struggling to adjust to a new school, Emily punched a hole in the wall and threatened to harm herself. Her worried dad drove her to the emergency department (ED).

Emily could have ended up like so many patients with behavioral health conditions in the ED. She could have waited 11.5 hours (the national average) for laboratory tests, x-rays, and a psychiatric assessment.¹ Her distress might have intensified as her father watched helplessly. Staff would have struggled to calm her while juggling a dozen other patients. Instead, a different process unfolded.

Emily’s emergency physician immediately put her at ease by asking questions, listening, and validating her feelings. Using screening tools, he determined she was at low risk for suicide and did not require comprehensive laboratory testing. While waiting on the laboratory test, Emily met with the telepsychiatrist, who provided a brief assessment and targeted counseling and then helped her, her dad, and the emergency physician to create a discharge plan. After only 90 minutes, Emily was cleared to go home. As she left, she smiled and teased her dad for wearing his “dorky” orange Crocs to the hospital.

A Need for Collaboration

Stories like Emily’s matter, because psychiatric emergencies are becoming increasingly common. Between 2019 and 2021, the percentage of US adults reporting anxiety or depression symptoms nearly quadrupled to 41%.² Today, approximately 1 in 8 ED visits involves a behavioral health condition.³ The number of individuals presenting to the ED with suicidal ideation has increased 414% in the past decade.⁴ As a result, EDs have become one of the nation's most important access points for mental health care. Unfortunately, processes and protocols for handling psychiatric emergencies have not kept pace.

Many patients with psychiatric conditions endure unnecessary laboratory tests and imaging. Once medically cleared, they can wait hours for psychiatric consultations. They are more likely than other patients to be admitted, and the wait for an inpatient psychiatric bed can average 30 hours in some states.^3,5 Meanwhile, they are “boarded” in a noisy, chaotic environment—sometimes on gurneys in hallways, guarded by sitters, and without medication or treatment. If they become (understandably) agitated, they are sedated and physically restrained.

What made the difference for Emily? In her case, 2 specialties—emergency medicine and psychiatry—worked together to provide early, appropriate treatment and plan for a safe discharge.

As a psychiatrist (Scott Zeller, MD) and an emergency physician (Seth Thomas, MD) within an integrated, multispecialty practice, we have decades of combined experience handling psychiatric emergencies. We share a commitment to providing prompt, evidence-based, compassionate care in the least restrictive setting. Together, we have led the development of shared tools, protocols, and pathways to help patients with psychiatric conditions and the clinicians who care for them.

In this article, we share practical insights and recommendations to improve interdisciplinary collaboration in what has often been a long-standing sore point: the relationship between emergency physicians and psychiatrists. We encourage our psychiatric clinician readers to discuss these suggestions with their emergency physician colleagues—or even share this story with them.

ED 101 for Psychiatrists

If you have not spent much time in “the pit” since residency, a few reminders may be helpful. First, the Emergency Medical Treatment and Active Labor Act requires EDs to assess and attempt to stabilize every patient who arrives.⁶ Often, clinicians must operate with limited information and minimal resources. Some patients with psychiatric conditions are intoxicated and unable to communicate their history or medication list. Others are brought in by first responders or family members who turn around and leave them.

Consulting and admitting psychiatrists might question the streamlined workups they receive from the ED. But remember that emergency physicians are simultaneously managing traumas, strokes, heart attacks, and other life-threatening emergencies. Their priority is not to precisely diagnose the psychiatric condition but to stabilize patients medically while minimizing risk.

If you are concerned about treatment delays and unnecessary admissions, consider that most emergency physicians have limited psychiatric training.⁷ Because of this, they can feel inexpert in psychopharmacology and be reluctant to prescribe psychiatric medication. And they may be more likely to admit patients when that appears to be the safest option.

Fortunately, emergency physicians and psychiatrists also have plenty in common. We are both frustrated by boarding and other system failures. We believe that patients, families, and providers deserve better. And although we cannot fix everything, there are practical ways we can work together to provide faster, better, and more humane care.

What Emergency Physicians Can Do

The first hour for a patient with a psychiatric condition in the ED is crucial. Those who are seen punctually, offered therapeutic treatment, and engaged as partners in their care often have smoother courses, shortened lengths of stay, and better outcomes.⁸

Prioritize Human Connection

Patients experiencing psychiatric emergencies are often frightened, overwhelmed, and vulnerable. A calm voice, trauma-informed approach, and genuine empathy can be more effective than any medication. When emergency clinicians approach patients as partners rather than problems to manage, trust develops and agitation often decreases.

Take Thorough Histories

A detailed ED assessment can greatly assist the receiving psychiatrist and improve care downstream. Suicidal ideation and hallucinations are only part of the story. When possible, also document recent stressors, treatment history, medication adherence, social circumstances, and events leading up to the current crisis.

Eliminate Overprocessing

Not every patient with a psychiatric condition needs comprehensive laboratory testing for medical clearance. Instead, consider using an evidence-based screening tool for these patients, such as SMART Medical Clearance, to guide your workup and eliminate unnecessary overtesting.⁹ For many patients at low risk, a standard history and physical will suffice.¹⁰

Initiate Early Treatment

Appropriate therapies can shorten ED stays, improve outcomes, and help patients feel more comfortable and cooperative.⁸ When clinically appropriate, treat acute agitation, anxiety, psychosis, and withdrawal with medications. Restart any home medications and address concurrent medical issues such as asthma, diabetes, or hypertension.

Develop Your Knowledge

Emergency physicians can learn to manage many psychiatric emergencies independently. Take CME courses on medication management and de-escalation. Add tools such as SMART and risk stratification to your kit. Consider adopting a program such as Emergency Psychiatric Intervention, which provides tools and training for your entire department.¹¹

What Psychiatrists Can Do

Even before a patient with a behavioral health condition leaves the ED, psychiatrists can act to remove care barriers, minimize delays, and improve outcomes.

Consult Early

A timely consultation is a huge gift to the patient, family, and ED team. Long waits are stressful for all involved and costly for the hospital, and they contribute to crowding.¹² Even preliminary recommendations can help emergency clinicians move care forward while coordinating a formal psychiatric evaluation.

Share Relevant History

To provide safe and appropriate care, emergency physicians may need access to prior diagnoses, medication histories, treatment plans, and background information. Psychiatrists sometimes hesitate to share patient health information due to privacy concerns. However, emergency situations (including ED visits) are clear legal exceptions to the Health Insurance Portability and Accountability Act, allowing providers to disclose relevant protected health information without signed consent.¹³

Facilitate Faster Admissions

As an admitting psychiatrist, work with the ED to coordinate an appropriate (not exhaustive) workup. Research shows that many routine laboratory tests and imaging studies add little value for appropriately screened patients with psychiatric conditions.¹⁴ A CT scan of an individual with a multiyear documented history of psychosis without any other new symptoms is unlikely to reveal anything useful.

Do not think the emergency physicians will not notice if you try to delay a transfer until after your shift by requesting extra tests and procedures. That is an old trick. If you earn a reputation for being difficult, you will not receive favors or the benefit of the doubt from your ED ever again.

Advise on Disposition

Patients with psychiatric conditions are admitted at over twice the rate of all patients—probably because discharges often feel risky to emergency physicians.³ Your ED colleagues greatly value your advice on risk stratification, admissions decisions, and discharge planning. The earlier you reach out, the more value you can offer and the less time you will waste negotiating over admissions.

For Both: Advocate for System Change

Emergency physicians and psychiatrists can work together to educate hospital leadership about potential solutions. New care delivery models can greatly improve psychiatric patient outcomes while reducing boarding and improving the hospital’s bottom line.

One example is the emergency psychiatric assessment, treatment, and healing (EmPATH) unit, which is now present in over 60 hospitals nationwide (with over 100 expected by 2027). EmPATH units are hospital-based emergency stabilization departments created specifically to address psychiatric boarding. They offer medically stable patients with behavioral health conditions a soothing, therapeutic setting distinct from the ED, with prompt access to psychiatrists and treatment.

Research has consistently demonstrated that EmPATH units dramatically reduce boarding and the need for one-to-one sitters, decrease physical restraint use by over 95%, and lessen 30-day ED revisits by over 25%—all while improving patient satisfaction and preventing workplace violence.^15,16 Over 70% of even involuntarily detained patients in EmPATH units are stabilized and discharged to community settings, freeing scarce psychiatric beds for those who truly have no alternative.¹⁶

Better Is Possible

When psychiatrists and emergency physicians view each other as allies, something remarkable happens. Both specialties start picking up the phone, discussing cases, and solving issues collaboratively. This ensures patients receive compassionate, timely, expert treatment during one of the most vulnerable moments of their lives. So many unfortunate situations we have witnessed in our careers could have been prevented by emergency and psychiatric providers communicating openly and deciding concurrently on the best course of action. That is what our patients deserve. And together, we can achieve it.

Dr Zeller is vice president of acute psychiatry at the physician partnership Vituity and assistant clinical professor of psychiatry at the University of California, Riverside School of Medicine. He is an editorial board member of Psychiatric Times.

Dr Thomas is a board-certified emergency medicine physician and clinical transformation leader based in Northern California. He is the director of clinical transformation for Vituity and Inflect Health.

References

1. Weiss AP, Chang G, Rauch SL, et al. Patient- and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med. 2012;60(2):162-171.e5.

2. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049-1057.

3. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Agency for Healthcare Research and Quality; 2010. Accessed July 1, 2026. https://www.ncbi.nlm.nih.gov/books/NBK52659/

4. Bommersbach TJ, Olfson M, Rhee TG. National trends in emergency department visits for suicide attempts and intentional self-harm. Am J Psychiatry. 2024;181(8):741-752.

5. Tuttle GA. Access to Psychiatric Beds and Impact on Emergency Medicine. American Medical Association. 2008. Accessed July 1, 2026. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/about-ama/councils/Council%20Reports/council-on-medical-service/a08-cms-psychiatric-beds-emergency-medicine.pdf

6. Emergency Medical Treatment and Active Labor Act, 42 USC §1395dd (1986).

7. Pickett J, Haas MRC, Fix ML, et al. Training in the management of psychobehavioral conditions: a needs assessment survey of emergency medicine residents. AEM Educ Train. 2019;3(4):365-374.

8. Katiki C, Ponnapalli VJS, Desai KJ, et al. Enhancing emergency room mental health crisis response: a systematic review of integrated models. Cureus. 2024;16(11):e74042.

9. Festini D, Wüthrich F, Christ M. External validation of the SMART Medical Clearance form for emergency patients with psychiatric manifestations. Dtsch Arztebl Int. 2024;121(4):107-113.

10. Thrasher TW, Rolli M, Redwood RS, et al. 'Medical clearance' of patients with acute mental health needs in the emergency department: a literature review and practice recommendations. WMJ. 2019;118(4):156-163.

11. Emergency Psychiatric Intervention. Vituity. 2021. Accessed June 23, 2026. https://www.vituity.com/healthcare-insights/emergency-psychiatric-intervention/

12. Nicks BA, Manthey DM. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int. 2012;2012:360308.

13. Does HIPAA permit health care providers to share protected health information (PHI) about an individual who has mental illness with other health care providers who are treating the same individual for care coordination/continuity of care purposes? US Department of Health and Human Services. January 4, 2018. Updated December 28, 2022. Accessed June 23, 2026. https://www.hhs.gov/hipaa/for-professionals/faq/3007/when-does-hipaa-allow-hospital-notify-individuals-family-friends-caregivers-patient-hospitalized-psychiatric-hold-been-admitted-discharged/index.html

14. Parmar P, Goolsby CA, Udompanyanan K, et al. Value of mandatory screening studies in emergency department patients cleared for psychiatric admission. West J Emerg Med. 2012;13(5):388-393.

15. Kim AK, Vakkalanka JP, Van Heukelom P, et al. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. Acad Emerg Med. 2022;29(2):142-149.

16. Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med. 2014;15(1):1-6.