Introduction
The promise of 988 and the new National Guidelines for Behavioral Health Crisis Care offer a different path for individuals experiencing a crisis related to mental health, substance use, or other emotional or trauma-related challenges. The guidelines outline the ideal of immediate access to care for anyone, anytime, anywhere. This care is designed to be the best practice for behavioral health care emergency crisis response and, in its implementation, providers should collaborate effectively and sensitively with the persons served. There is often a tension present in crisis care, involving balancing safety with minimizing trauma by using the least restrictive supports for an individual’s needs. In this context, it is important to realize that crisis contacts can help set the stage for subsequent engagement and entry into longer-term treatment. In the emerging crisis continuum of services, the role of law enforcement and hospital Emergency Department (ED) use is de-emphasized in favor of utilizing first responders through crisis call centers, mobile behavioral health teams, and behavioral health Crisis Receiving Centers (CRCs) equipped and staffed to manage the full range of crisis mental health and substance use challenges in the community. Even with a shift in roles, partnerships—including with law enforcement and EDs—are important across crisis systems, as these entities are still needed. Yet it will be increasingly critical to help demonstrate ways for these partnerships to improve and to coordinate and build a system that serves people in the least restrictive way.
emerged as its own complex interplay of services across a continuum that is receiving a great deal of national attention. The Management of Medical Stabilization Within Crisis Receiving Centers model, for example, with its “no wrong door” principles, reduced hospital costs, and matching of appropriate service levels, helps to improve access to care in ways that provide better outcomes in spaces that are safe, trauma-informed, and inclusive of both clinical staff and people with lived experience of mental health issues, substance use, or trauma recovery. To realize the full benefit of this model, CRCs must always say yes to law enforcement or other first responder drop-offs, even when both medical and behavioral health challenges coexist. Emergency behavioral health CRCs should have the infrastructure of medications; staff with medical care expertise; and training in triaging and managing medical, psychiatric, and substance use needs using the appropriate medical tools to accomplish this directive safely and effectively and to help avoid over reliance on EDs. In the 2024 technical assistance brief Connected and Strong: Strategies for Accessible and Effective Crisis and Mental Health Services, these points are emphasized given the importance of uniting to strengthen system capacity in multiple domains.
Often, out-of-hospital responses delivered through receiving centers require the capability to prescribe and administer medications as one of the tools to support persons in crisis in an emergency moment, and they require medications to start or restart treatment according to best practices for a range of mental health and substance use care needs. When persons present for short-term stays in out-of-hospital facilities, they often also have acute or chronic medical conditions. There may be concerns about the role of medical issues in their psychiatric presentation. There may also be concerns about managing their medical problems safely and effectively during crisis care. Persons presenting in crisis often do not need medical clearance in an ED before starting behavioral health emergency crisis care. However, requiring people to pass through a hospital ED is too often a prevailing pattern in much of the country. When the behavioral health crisis system cannot serve all and say yes to everyone who enters its doors (just like a hospital ED), more people will begin their journey in an ED or the justice system or may not seek access to needed care due to the barriers at entry. The current trajectory presents a particular risk for criminalizing behavioral health needs within marginalized populations, as demonstrated by significant racial disparities in outcomes and care in the current system.
Crisis Presentations: What May Arise on Any Given Day
People present to behavioral emergency CRCs 24 hours a day, 7 days a week, 365 days a year. Usually they arrive voluntarily, but sometimes they are brought against their will while experiencing a behavioral health crisis. For policymakers working at a distance from the actual service, it can be helpful to consider situations that may affect that person’s ability to be served. The examples below highlight real concerns about medical needs that could impact the ability of the person to be safely served at the crisis care facility as opposed to being turned away and sent back to the community or being sent to an ED not designed to meet their behavioral health care needs. All scenarios are based on actual but de-identified clinical examples provided by the authors from their experiences.
What Medications Are Needed for Crisis Care?
What Medications Are Needed for Crisis Care? Medications are one of many tools used in crisis care. They can be lifesaving and can help immediately treat symptoms. It would not be possible to deliver effective emergency physical health care for a broad range of issues presenting in a hospital ED without medications and best practices of emergency care. This is also true for emergency crisis services for a broad range of behavioral health issues. Having access to medications can make the difference in being able to say yes to everyone in crisis coming to a crisis facility. Medications can be best practice in some situations, offering relief, symptom improvement, or harm reduction, especially when combined with other crisis care therapeutic tools.
People may present to crisis facilities with challenges such as suicidality, sleep disturbances, depression, mania, psychosis, trauma, substance use, and many other concerns. Sometimes they come into facilities voluntarily, and sometimes on an involuntary basis. Occasionally, individuals may have severe agitation, causing them to be at imminent risk of self-harm or harm to others at the time of arrival. This risk of imminent harm may be related to mental health challenges, substance use effects such as intoxication or withdrawal, traumatic experiences, or medical causes. Without medications as one of the available tools, those people may not be able to be served safely and effectively.
Additionally, people often present for short-term stays of several days in crisis units. They may need medications for fundamental medical issues such as hypertension, diabetes, skin infections, pain, and other concerns. They may or may not have their medications with them, they may not have been on their medications for some time, and they may face social or economic barriers to obtaining their medications. Sometimes, they may not have received medical care for a prolonged period and may be open to starting work toward improving their physical health as part of their crisis response plan.