Bibliography - Special Considerations

Resources Related to Improving Treatment of Behavioral Health Patients in Emergency Department Settings
* Resources that are not specific to behavioral health are preceded by an asterisk.

Agency for Healthcare Research and Quality (2012). Service Delivery Innovation Profile: Emergency medical technicians use checklist to identify intoxicated individuals who can safely go to detoxification facility rather than emergency department. Available at:

  • This AHRQ profile describes a Colorado program in which trained EMTs used a checklist to identify intoxicated individuals who could be safely transported directly to a local detox facility, thus avoiding expensive visits to crowded, resource-constrained emergency departments.

See the related article:
Ross DW, Schullek JR, Homan MB. EMS triage and transport of intoxicated individuals to a detoxification facility instead of an emergency department. Annals of Emergency Medicine 2013; 61(2): 175-84.
Available at:

Agency for Healthcare Research and Quality (2012). Service Delivery Innovation Profile: Hospital Partners with Residential Treatment Facility to Offer Alternative Setting to Intoxicated Patients, Reducing Emergency Department Length of Stay. Available at:

  • This AHRQ profile describes a Louisville, KY program in which a hospital partnered with a residential alcohol treatment center to offer medically stable emergency department patients with acute alcohol intoxication an alternative treatment setting, leading to lower emergency department length of stay, cost savings, and anecdotal reports of improved patient outcomes.

Baker SJ, Schynoll W, Smith D, Kennedy-Oehlert J, Shupe R, Sullivan F. (8 pages) Managing Drug-Seeking Behaviors & Super Users in the Emergency Department. Studer Group (2011).
Available at:

  • This paper discusses how to deal with patients exhibiting chronic pain or drug seeking behaviors.

Center for Substance Abuse Treatment. Addressing Co-Occurring Disorders in Non-Traditional Service Settings. COCE Overview Paper 4. DHHS Publication No. (SMA) 07-4277. Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2007. Available at:

  • This white paper notes that many people with co-occurring MH/SA disorders never see providers who specialize in those disorders, but may find themselves in a variety of other settings, including emergency rooms, where identification and outreach could occur. While non-SA/MH settings should not be expected to provide comprehensive SA/MH services, they afford important opportunities for identification and engagement of persons with co-occurring disorders and can serve as gateways to integrated systems of care.

Hansen GR. The Drug-Seeking Patient in the Emergency Room. Emergency Medicine Clinics of North America 2005; 23: 349–365. Available at:

  • “It has been estimated that an emergency department with 75,000 patients per year can expect up to 262 monthly visits from fabricating drug-seeking patients. Distinguishing drug seekers from patients who have a legitimate therapeutic need is not always possible in the acute care setting, yet physicians have the dual obligation to relieve pain and to protect susceptible patients from the consequences of abusing or becoming addicted to drugs….In this article, the psychoactive properties of opioids, abuse, addiction, and pseudoaddiction are discussed, and various strategies for managing them are reviewed.”

Substance Abuse and Mental Health Services Association.Center for Substance Abuse Treatment. Treatment, Volume 2: Addressing Co-Occurring Disorders in Non-Traditional Service Settings. COCE Overview Paper 5. DHHS Publication No. (SMA) 06-XXXX. Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2006.

Substance Abuse and Mental Health Services Administration. The DAWN Report (multiple issues). Available at:

  • The Drug Abuse Warning Network (DAWN) is a national public health surveillance system that collects data on drug abuse-related visits to emergency departments and drug abuse-related deaths. The DAWN Report is published by SAMHSA’s Office of Applied Studies. Multiple issues of the DAWN Report that deal with drug-related emergency department visits (e.g., visits involving pharmaceutical misuse/abuse by older adults, visits for drug-related suicide attempts, etc.) are available at SAMHSA’s web site.

Agency for Healthcare Research and Quality (11/20/2013). Quality Tool: Eating Disorders in the Emergency Department: Critical Points for the Recognition and Medical Management of Individuals with Eating Disorders in the Acute Care Setting. Available at:

  • The AHRQ brief describes a guide for emergency department staff and clinicians that is intended to promote recognition and prevention of medical morbidity and mortality associated with eating disorders. The tool itself is available at:

Agency for Healthcare Research and Quality (11/20/2013). Service Delivery Innovation Profile: Emergency Department Screening Identifies Many Patients with Possible Eating Disorders, Suggesting Potential to Facilitate Earlier Diagnosis and Connection to Treatment. Available at:

  • This AHRQ profile describes a five-question survey given to ED patients that identifies those with potential eating disorders.

Dooley-Hash S, Lipson SK, Walton MA, et al. Increased emergency department use by adolescents and young adults with eating disorders. International Journal of Eating Disorders 2013; 46(4): 308-315.
Available at:

  • Patients with eating disorders utilize the ED more frequently than those without and commonly present for complaints seemingly unrelated to their eating disorder.

Dooley-Hash S, Banker J, Walton M, et al. The prevalence and correlates of eating disorders among emergency department patients aged 14-20 years. International Journal of Eating Disorders 2012; 45(7): 883-90.
Available at:

  • Eating disorders are common among patients aged 14-20 years presenting to the ED and are associated with high rates of psychiatric comorbidity.

Cooper JL, Masi R. Child and Youth Emergency Mental Health Care: A National Problem. National Center for Children in Poverty; July 2007. Available at:

  • This report from the NCCP at Columbia University reviews the state of services for children and youth who visit hospital EDs for mental health-related reasons and provides an overview of the challenges associated with such visits. It discusses the policy implications of using ED services for children and youth with mental health problems and makes recommendations for policy action.

Dolan MA, Fein JA, and The Committee On Pediatric Emergency Medicine
Technical Report: Pediatric and Adolescent Mental Health Emergencies in the Emergency Medical Services System. Pediatrics 2011; 127. Available at:

  • A May 2011 American Academy of Pediatrics report that addresses the roles emergency departments play in emergency mental health care of children and adolescents.

Hamm MP, Osmond M, Curran J, Scott S, Ali S, Hartling L, Gokiert R, Cappelli M, Hnatko G, Newton AS. A systematic review of crisis interventions used in the emergency department: recommendations for pediatric care and research. Pediatric Emergency Care 2010 December; 26(12): 952–962.
Available at:

  • Studies have demonstrated that the use of specialized care models for mental health care can reduce hospitalization, return ED visits, and length of ED stay. Adult-based studies provided recommendations for pediatric research including a focus on triage and restraint use.

AHRQ Health Care Innovations Exchange (12/4/2013)
Service Delivery Profile: Statewide Partnership Provides Mental Health Assessments via Telemedicine to Patients in Rural Emergency Departments, Reducing Wait Times, Hospitalizations, and Costs.
Available at:

  • Through a statewide telemedicine program, psychiatrists evaluate patients with mental health issues who present at rural hospital emergency departments, leading to reductions in wait times, inpatient admissions, and costs; increased attendance at followup visits; and high levels of patient and clinician satisfaction.

National Health Care for the Homeless Council. Medical Respite Tool Kit. Accessed December 16, 2013.
Available at:

  • The NHCHC web site has a variety of resources related to medical respite programs, including this tool kit. Medical respite is short-term residential care for homeless persons who have a medical injury/illness and may also have a mental illness or substance use disorder, who are too ill or frail to recover on the streets but not ill enough to be in a hospital. This treatment approach helps hospitals to provide acute or post-acute care to individuals who might otherwise return to the emergency department. The tool kit provides information to help organizations and advocates plan, develop, and sustain medical respite programs.

Nielsen D, Klein EA. The Care of Mental Health Patients in the Emergency Department: One Rural Hospital’s Approach. Journal of Emergency Medicine 2009; 37(4): 430–432.
Available at:

  • In a rural Michigan hospital, four mental health professionals were trained to complete crisis assessments for patients in the ED, and an Access Center staffed 24/7, was added to the ED to meet the mental health needs of ED patients as quickly as possible. Patients with mental health needs now receive services in a timely manner (< 30 min) despite steadily increasing numbers of patients needing mental health services. The addition of an Access Center to the ED resulted in the provision of mental health services within time limits acceptable to both patients and medical staff.

Last updated January 2014

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