America’s mental health crisis is evolving. Are we prepared?

From the days of Ben Franklin’s firefighting club to the professionalization of the modern fire service, transition has been a constant in our field. The latest transition: The fire service is slowly turning its attention to the personal toll that our duty takes on the health and well-being of our workforce.

Such long overdue attention on our own mental health highlights, in part, how far we must go before achieving effective and compassionate care for others suffering from mental illnesses.

Fire service leaders are working to find ways to break through barriers and stigma to address depression, anxiety, post-traumatic stress, substance misuse and use for themselves, their friends and their colleagues. The emergence of programs – like those involving peer support, having support K9s in the firehouse, and the International Association of Fire Fighters Center of Excellence for Behavioral Health Treatment and Recovery – shows the positive changes being made toward acknowledging that people have their limits. If such realizations are true for members of the fire service, the same must also be true for the public whom we faithfully serve day in and day out, and we must be ready to meet their needs.

A CRITICAL HEALTHCARE NEED

The National Alliance on Mental Illness reports that in 2019, one in five (51.5 million) U.S. adults experienced mental illness, with 13.1 million of those suffering from a serious illness.

Focusing on youth, in 2016, 16.5% (7.7 million) of U.S. youth experienced a mental health disorder. Research shows that 50% of all lifetime mental illness begins by age 14 and 75% by age 24.

Suicide rates have increased in the United States by 35% since 1999, and suicide is the second-leading cause of death among individuals age 10-34 and the 10^th overall cause of death in the nation.

The COVID-19 pandemic is exacerbating this problem, with state shutdowns negatively impacting mental and emotional health, and research shows that those under 18 are experiencing the highest rates of anxiety, depression and other mental health issues.

EMS ROLE IN TREATING MENTAL HEALTH PATIENTS

One of the earliest studies examining life squad/EMS use in the U.S. found that, “While anxiety-related visits were the least likely to use an ambulance, both substance abuse and suicide-related visits were highly predictive of ambulance transport.” And the prevalence of mental illness and substance use calls for service continues to grow. Just 10 years following the study, medical professionals added excited delirium, which includes anxiety, altered mental status or agitation, mood disorders and psychosis, to a growing list of mental illnesses encountered by EMS providers. Notably, EMS providers are encouraged to include law enforcement as part of the routine response in an effort to maintain scene safety, despite calls by community activists to exclude law enforcement agencies from such calls for service.

Further, EMS providers often do not believe that mental health illness or alcohol intoxication is a medical emergency requiring or justifying their services. As reported in one study, “These attitudes fit into larger patterns of institutional stigma that are often brought to bear on patients with mental and behavioral health needs.” EMS providers’ failure or refusal to acknowledge mental or behavioral illness as a medical condition in part contributes to law enforcement dealing with medical illness while simultaneously lacking the necessary training and resources to provide care.

CRISIS INTERVENTION TRANSFORMATION

In the wake of the May 2020 death of George Floyd while in police custody in Minneapolis, many communities are now facing pressure to defund (more accurately, reallocate) portions of police budgets to pay for programs intended to combat issues like addiction and homelessness for which mental illness is a contributing factor. These programs often feature mental health teams, a movement that mirrors recent efforts by first responders who have launched Quick Response Teams (QRTs) to guide patients struggling with substance use and abuse to treatment and recovery programs.

QRTs are commonly linking with social workers and substance use counselors to meet people where they are, in other words, to give people what they need, when they need it. To fulfill this commitment, we must meet people where they are both physically and psychologically. It is not feasible or practical to expect those in crisis to recognize they need help on their own. We have all seen countless examples of patients who are unable to recognize or act on their own to request help in the midst of a crisis.

Focusing on harm reduction strategies and programs is an important step. Incrementally less harmful behavior is progress, although it may not fit someone else’s expectations. Connecting patients with programs to address their needs while guiding them to sobriety is an incremental step toward long-term recovery and mental wellness. In essence, such programs broadly fall under the heading of community paramedicine or mobile integrated healthcare.

If your agency finds itself called upon to explore the implementation of a Mental Health Response Team, the opioid epidemic offers a roadmap to help guide your efforts. A 2019 opinion piece published by the American Medical Association detailing lessons learned from the opioid crisis cautions practitioners to avoid simple solutions for complex problems, encourages reliance on high-quality clinical evidence, highlights the critical need to obtain proper training and education in an effort to limit susceptibility of erroneous medical claims and the need to recognize various conflicts of interest.

A clear realization from America’s opioid epidemic is that substance use disorder can (and has) impacted every socioeconomic class throughout every community in the nation. These same lessons are certainly applicable to the mental health crisis facing our communities today.

OPPORTUNITIES FOR IMPROVEMENT

Recognition and acceptance of our own limitations should open our eyes to existing needs within our own community. Partnerships are critical. We don’t know what we don’t know. It is imperative that EMS providers consult with specialists who function in the field, much the same way EMS providers learn from cardiac specialists, labor and delivery providers, and other similar specialists.

The hospital emergency department has become the default destination for all EMS transports, including psychiatric emergencies. A five-year study of EMS transports in Alameda County, California, found EMS effectively and appropriately identified patients who were safely diverted to a dedicated psychiatric facility rather than the emergency room, resulting in improved patient experience while simultaneously reducing the burden on the emergency department.

A growing momentum exists for challenging the idea that EMS providers can only deliver patients to the ER. Fire service leaders must work to develop and support legislation and protocols that facilitate delivering patients to appropriate care providers. Expectant mothers already bypass the ER and head directly to labor and delivery, why not target the right destination for individuals needing psychiatric care or direct admittance to substance use and recovery programs as medically appropriate?

CONTINUE TO LEARN, EVOLVE

Socrates said, “I know that I know nothing.” Such a mindset primes first responders to continue to learn and ultimately improve the service delivery model they offer their communities. The inability to successfully recognize an individual experiencing a mental health crisis negatively impacts the patient, the provider and ultimately the community. Such system failures also tend to garner national attention. EMS must seek to improve the quality of its training and work to establish successful pathways for delivering medically appropriate care to those in need. The end result may just be a life saved.