On a recent shift at a Chicago emergency department, Dr. William Sullivan treated a newly homeless patient who was threatening to kill himself.
"He had been homeless for about two weeks. He hadn't showered or eaten a lot. He asked if we had a meal tray," said Sullivan, a physician at the University of Illinois Medical Center at Chicago and a past president of the Illinois College of Emergency Physicians.
Sullivan said the man kept repeating that he wanted to kill himself. "It seemed almost as if he was interested in being admitted."
Across the country, doctors like Sullivan are facing a spike in psychiatric emergencies - attempted suicide, severe depression, psychosis - as states slash mental health services and the country's worst economic crisis since the Great Depression takes its toll.
This trend is taxing emergency rooms already overburdened by uninsured patients who wait until ailments become acute before seeking treatment.
"These are people without a previous psychiatric history who are coming in and telling us they've lost their jobs, they've lost sometimes their homes, they can't provide for their families, and they are becoming severely depressed," said Dr. Felicia Smith, director of the acute psychiatric service at Massachusetts General Hospital in Boston.
Visits to the hospital's psychiatric emergency department have climbed 20 percent in the past three years.
"We've seen actually more very serious suicide attempts in that population than we had in the past as well," she said.
Compounding the problem are patients with chronic mental illness who have been hurt by a squeeze on mental health services and find themselves with nowhere to go.
On top of that, doctors are seeing some cases where the patient's most critical need is a warm bed.
"The more I see these patients, the more I realize that if it's sleeting and raining outside, the emergency room is the only place they have," said Dr. R. Corey Waller, director of the Spectrum Health Medical Group Center for Integrative Medicine in Grand Rapids, Michigan.
Government agencies such as the National Institutes of Mental Health, the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration could not provide fresh data on use of psychiatric services in recent years.
But doctors from more than a dozen hospitals nationwide, mental health advocacy groups and state-funded agencies told Reuters they are all seeing a marked increase in psychiatric emergencies.
The National Association of State Mental Health Program Directors (NASMHPD), an organization of state mental health directors, estimates that in the last three years states have cut $3.4 billion in mental health services, while an additional 400,000 people sought help at public mental health facilities.
In that same time frame, demand for community-based services climbed 56 percent, and demand for emergency room, state hospital and emergency psychiatric care climbed 18 percent, the organization said.
"This wasn't one round of cuts," says Ted Lutterman, director of research analysis at NASMHPD Research Institute. "It was three or four for many states, and multiple cuts during the year."
If the economy doesn't improve, next year could be worse because many community mental health agencies are cutting programs and using up reserve funds, says Linda Rosenberg, president of the National Council for Community Behavioral Healthcare.
"It's been horrible," she said. "Those that need it the most - the unemployed, those with tremendous family stress - have no insurance."
In the emergency room, this increased demand has meant doctors and social workers are spending hours and sometimes days trying to arrange care for psychiatric patients languishing in the emergency department, taking up beds that could be used for traditional types of trauma.
More than 70 percent of emergency department administrators said they have kept patients waiting in the emergency department for 24 hours, according to a 2010 survey of 600 hospital emergency department administrators by the Schumacher Group, which manages emergency departments across the country.
Ten percent said they had "boarded" patients for a week or more.
And many hospitals are not prepared for the increased caseload of psychiatric patients, says Randall Hagar, director of government affairs for the California Psychiatric Association.
California cut $587 million in state-funded mental health services in the past two years, the most of any state, according to the National Alliance on Mental Illness, a patient advocacy group.
"They don't have secure holding rooms. They don't have quiet spaces. They don't have a lot of things you need to help calm down a person in an acute psychiatric crisis," Hagar said.
"Often you have a patient strapped to a gurney in a hallway outside of the emergency department where social workers are desperately trying to find an inpatient bed," he said.
In North Carolina, the state has cut its inpatient psychiatric capacity by half since 2005, says Dr. Bret Nicks, an emergency physician at Wake Forest Baptist Medical Center in Winston-Salem and a spokesman for the American College of Emergency Physicians.
'The forgotten patient population'
Nicks points to a report from the Institute of Medicine released in 2006 that found U.S. emergency departments were already overtaxed and overcrowded.
"Now you are adding in patients who are unsafe to leave but yet have nowhere to go," he said. "I consider patients with acute psychiatric needs as really the forgotten patient population in the U.S. right now."
Dr. Stephen Anderson is an emergency department doctor at Auburn Regional Medical Center, a mid-size suburban hospital outside of Seattle.
"When the economy is hurt they are some of the first to drop off the healthcare rolls," he said of local residents in the largely blue-collar community.
Anderson, who heads the Washington Chapter of the American College of Emergency Physicians, said the state has lost a third of its inpatient psychiatric beds in the past decade.
Lately he is seeing a marked escalation in patients with psychiatric problems turning up in the emergency department. In early December, a third of its beds were occupied with people in a psychiatric crisis who were not safe to return to the community.
The problem extends out to small towns.
Sullivan splits his time between the big emergency department at the University of Illinois Medical Center at Chicago and St. Margaret's Hospital, a tiny facility in Spring Valley, Illinois, about 100 miles southwest of the city.
On a recent shift, a young woman with schizophrenia arrived at the hospital. She had just lost her job and apartment and was living with relatives. She could not afford the medications that were keeping her illness in check.
The woman asked Sullivan to switch her prescriptions to drugs that could be found on the $4 discount list at Wal-Mart and other discount stores.
"I didn't feel comfortable doing that," Sullivan said, noting that emergency physicians are being asked to deliver specialized care that should be handled by a psychiatrist.
He found a healthcare facility about 25 miles away with a psychiatrist who could help, but even that presented a problem for the woman, who had no way of getting to the appointment.
"It's almost akin to having a cardiac patient come in and say, 'I need someone to adjust my defibrillator.' In the emergency department, we can do a lot, but there are some things we have to leave with the specialists," he said.