When Does a Mental Health Challenge Become an Emergency, and Where Should You Go for Help?

By Paula Gaudino, MSW LCSW, Director of Inova Behavioral Health Services, Emergency Services

If you suddenly begin to have chest pain and shortness of breath, you likely know what to do: you head to the emergency room, because you might be having a heart attack. You know that a heart attack is a potentially life-threatening crisis. But what about if you had high blood pressure? It’s still a problem, and it raises your risk of all sorts of diseases, including emergencies like heart attack and stroke – but you don’t go to the ER because you have high blood pressure. Instead, you probably make an appointment to see your primary care doctor to get your high blood pressure fixed before it becomes a big problem.

The same thing is true for mental health conditions. There are life-threatening crises, which are emergencies and are best handled in the ER. But in many cases, as with the high blood pressure example above, the ER is not the best place to go for a mental health issue that is not an emergency. But unlike a heart attack versus high blood pressure, it can be much tougher to figure out when mental health symptoms constitute a crisis and when they do not.

What is a mental health crisis?

A crisis is a situation in which a person’s actions, feelings and behaviors can cause harm to themselves or others, or when their symptoms are so severe that they can’t meet their basic needs. A person in a mental health crisis should come to the ER right away.

A crisis can be triggered by a wide variety of factors, including trauma, isolation and stressors, but it’s unpredictable and varies from person to person. While we can’t predict when people will have a crisis, we can tell families and patients how to best approach it.

Come to the ER:

• When there is a high likelihood that as a result of their illness, feelings and behaviors, they will cause serious harm to themselves or others. As an example, a person who is discussing suicide or harm to others with plans and specifics would be considered at high risk of causing serious harm.
• When there is a good chance that they could suffer an injury because they lack the capacity to care for their basic human needs. For instance, a person demonstrating severe confusion, not recognizing people, getting lost, or not coming home might have a serious mental capacity concern.

What is an escalation in mental health symptoms (pre-crisis), and how is it different from a mental health crisis?

Sometimes, in retrospect, individuals or family members are able to identify warning signs that they didn’t see at the time. These warning signs can signal an escalation, or increase, in the severity of a person’s mental health challenges. If we can catch an escalation at the precrisis stage, we may be able to help the person avoid a full-blown crisis.

In a pre-crisis:

• A person with a known history of mental illness might decide to go off medication.
• A person might start to decompensate – not trusting people, not doing daily tasks, feeling paranoid.
• Some people will have an abrupt change in mental status – loved ones mat say they are “not acting like themselves.”
• A person may start talking about death and may give away belongings.
• Some people may have a significant change in mood – they may become withdrawn, sleep too much, or become aggressive.
• Others may not want to be around people.
• There may be a big change in a person’s sleeping habits and eating patterns.

These precrisis warning signs are not the time to come to the ER. Instead, you should go to your primary care doctor, or your psychiatrist, if you already have one, for help.

What happens in the ER?

The role of the ER is to assess the patient and determine what level of treatment the patient needs: Do they need to go to the hospital, or do they need to go back to the community and follow up with their primary care doctor or psychiatrist? The ER does not handle medication refills or medication adjustments.

Before you come to the ER, understand that you may face hours of waiting, only to be told to return home and handle the problem on an outpatient basis. We want patients to have a positive ER experience, but the reality is that the ER is not always the best answer for a person experiencing mental health issues. It’s best to consider the ER a last resort.

You are not alone: resources for mental health challenges

The good news is, there are lots of great community resources to help people facing an escalation in their mental health symptoms.

Inova Psychiatric Assessment Center can help patients avoid an ER visit, with same-day assessment and access to a psychiatrist. Think of it as urgent care for mental health.

Inova Behavioral Health Services’ Central Access Call Center is another great resource – you can ask questions, explain what the patient is experiencing, and be directed to the right level of help. Call 571-623-3500.

Other community resources include:

• The national suicide hotline – available 24 hours a day at 800-273-8255
• Crisis text line – text 741741 anytime for help
• REACH – a 24-hour crisis and referral line for individuals with developmental disabilities
• Community Services Board – crisis intervention services for any and all mental health crises

By learning the differences between a mental health crisis and an escalation or precrisis, you can help protect the mental health and well-being or yourself or a loved one.

If you or someone you know is having an immediate medical emergency related to mental health, please call 9-1-1 or go to the nearest emergency room. For more information about Inova Behavioral Health Services, visit us online.