Health & Medicine

Sacramento has a mental health crisis. Let’s shift from ‘emergency’ to strategy

Additional beds are set up in the hallway of an emergency room, which in California and other states are being crowded by an influx of mental health patients.
Additional beds are set up in the hallway of an emergency room, which in California and other states are being crowded by an influx of mental health patients. New York Times file

The mental health crisis in Sacramento is getting worse. We need a plan to turn things around.

On a recent Monday, I began my clinical rounds at UC Davis Medical Center’s emergency department providing initial care for 25 adults and four children suffering with psychiatric emergencies. These patients represented one-quarter of all patients in our emergency department that morning.

The company executive with depression and alcohol problems who had suicidal thoughts after losing custody of his children. A mother of two with brittle bipolar illness who developed manic symptoms after missing some doses of her mood stabilizer medication. A woman with schizophrenia and post-traumatic stress disorder who was hearing voices telling her to end her life.

All of these emergency department patients, who are considered a danger to themselves or others – or unable to care for themselves due to a mental illness – are placed on temporary, involuntary psychiatric holds. These are commonly referred to as “5150” holds.


Instead, they should be transferred to a psychiatric hospital for proper treatment. One patient, a woman with severe postpartum depression, asked pointedly, “Doc, if you diagnosed me with cancer, would I still be sitting here?”

The answer, sadly, was no.

With our area’s psychiatric bed shortage and under-resourced mental health system, these patients often end up spending days stuck in busy 24/7 emergency departments, unable to leave.

After the county decreased mental health services in 2009, the average number of daily psychiatric evaluations in the emergency department nearly tripled within the first year, according to a study published in the Annals of Emergency Medicine. Also, the average length of stay in the emergency department for patients in a mental health crisis increased by more than 50 percent during the same period.

For some patients, one 72-hour hold leads to another, and another, until days become a week or more. They spend all of that time spent in a busy, noisy, lights-always-on environment.

Emergency departments are not set up to serve people suffering from a mental health crisis. We can triage and stabilize someone with trauma, or bleeding badly from an accident, yet the emergency setting is not appropriate for engaging patients in long-term management of a psychiatric illness.

In fact, emergency departments are only licensed as 5150 holding facilities, available to keep patients for a short time until they are transferred to a psychiatric hospital.

Further complicating the situation is Sacramento County Mental Health’s electronic health record system, which is incompatible with the electronic records from the region’s federally qualified health centers and health systems. As a result, it is nearly impossible for hospital staff and primary care providers to share patient information and communicate efficiently with the mental health system.

Sacramento needs a strategic plan for addressing the mental health crisis, which affects every hospital and emergency department in our region.

I believe two key initiatives, implemented together, could put Sacramento on the road to mental health recovery. First, we must drastically increase the number of psychiatric hospital beds. Second, we must adopt what’s called a population health model of primary care – a model that integrates mental health services within primary care.

Our region needs an additional 100 to 200 psychiatric hospital beds to meet the needs of the current population, which has grown substantially. Yet the number of acute psychiatric hospital beds provided by Sacramento County Mental Health remains at pre-2009 levels.

The four large health systems in our region are working with Sacramento County to open more beds. Dedicated beds would reduce emergency department congestion and long wait times. They would also serve as sites to train the next generation of mental health professionals: psychiatrists, psychologists, nurse practitioners and physician-assistants.

Adopting a population health model of primary care is an essential step. In this model, mild to moderate mental illness is treated by a primary care provider who collaborates with on-site mental health professionals to deliver care.

More seriously ill patients are referred to psychiatrists and specialty mental health clinics. This model is called the collaborative care model. It improves health outcomes and reduces reliance on emergency departments.

Sacramento already has Federally Qualified Health Centers that care for the majority of Medi-Cal patient populations, and primary care networks that deliver care for their insured patients throughout our region. If these clinics increased mental health services using a population health approach, we could improve mental health care for patients in a way that is patient-centered and cost effective.

Fortunately, this July the state is accepting applications for the Health Homes Program, a model of care that would enable Federally Qualified Health Centers to hire integrated teams to focus on the most complex patients with both physical and behavioral health conditions, such as diabetes, high blood pressure, cardiac disease, depression, anxiety and trauma.

The program also would help patients address homelessness and other social determinants of health, well-known factors that predispose individuals to increased risk and poor health outcomes. Hopefully, every eligible center participates in this pilot program, which will provide some necessary funding towards a sustainable population health model.

These efforts will bolster the work of Sacramento County Department of Health Services, which has been an involved partner in finding innovative solutions to the mental health crisis.

By working together, we can rebuild Sacramento’s health care services. Our friends, family, neighbors, children and community need it.

Dr. Lorin Scher is the director of both Emergency Psychiatric Service and Medical Student Education in Psychiatry at UC Davis Health, as well as an associate professor.