Progress, in the world of medical science, is usually measured with modest gains and tradeoffs. A new medicine might be 5% more effective while being 3% more likely to cause a side effect, and the industry would call it a worthwhile achievement. When doctors and researchers start saying things like “halving the rate of hospitalization” or “effectively eliminating the need for intervention” at the cost of some basic remodeling and training, they know that a breakthrough is at hand.
Scott Zeller ‘82, a psychiatrist trained at Northwestern University’s Feinberg School of Medicine and chief of psychiatric emergency services at the Alameda (Calif.) Health System from 1996 to 2016, began the development of his own breakthrough as he faced the complex and acute challenges of mental health in the emergency room.
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Scott began his medical training and career in the relatively early days of emergency psychiatry – a discipline that treats potentially life-threatening incidents of mental health crises like drug overdoses, suicide attempts, violent psychotic episodes, or any situation where the medical emergency is caused by the patient’s disordered behavior. The field was only about as old as he was, having emerged in the 1960s as a course correction after the notorious mental institutions of the early 20th century. Since then, the world of psychiatric treatment has been discovering new answers to questions of how to care for those suffering the worst mental crises.
The need for those answers started to become more urgent in the early 2010s when an unprecedented increase in emergency mental health episodes began to push the medical system to its limits, especially in treating young adults and teenagers. According to a study published by the National Institutes of Health, the number of such ER patients doubled between 2011 and 2020, “including a 5-fold increase in the proportion of visits for suicide-related symptoms.”
Scott, like all ER doctors, was personally all too aware of this growing problem, but he didn’t realize how poorly it was being handled around the nation.
“I started reading national news stories that said, ‘There’s all these psychiatric patients in emergency departments that need to be hospitalized in psych wards, but they have to wait for hours or days to be taken in,’” Scott said. “They would always conclude by saying, ‘Clearly the solution is to have more inpatient beds,’ but I knew from our work at Alameda that, if you intervene in the mental health crisis right away, just like you would with an injury or asthma attack, the great majority of these folks would be able to go home the same day.”
Around that time, the American Association for Emergency Psychiatry had concluded what was called “Best Practices in the Evaluation and Treatment of Agitation,” or Project BETA, led by Scott and his colleague Garland Holloman, Jr. Their research, both inspired and implemented by Scott’s work within the Alameda Health System, created what was originally known as the Alameda Model. Today it’s known as Emergency Psychiatry Assessment, Treatment and Healing, or EmPATH Units. And, according to Kimberly Nordstrom, associate professor of psychiatry at the University of Colorado School of Medicine, speaking to medical news outlet Carlat, it “shook up the system and is now being used around the world.”
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Anyone who has known a medical professional who works in a hospital’s emergency department, or who is just a viewer of the distressingly realistic HBO medical drama The Pitt, can understand that it’s not a helpful environment for those suffering a mental crisis. Yet it’s where a patient must be taken if they are to survive the danger in which their crisis has placed them.
“When you go to the ER,” Scott explained, “you check in with a nurse who will do what’s called triage, which is prioritizing how quickly you’ll be seen by a caregiver. Unfortunately, psych patients would be placed pretty much as low on the triage scale as possible.”
When they were given treatment, they would receive it in the controlled chaos of a typical ER – “chaos” in that one might be surrounded by frantic doctors and nurses with patients who are in pain and anguish, and “controlled” in that patients are given little freedom to potentially complicate the treatment of life-threatening emergencies. Thus patients who are suffering mental health crises are placed in the same small, windowless rooms that are typically the only space available for those seeking emergency care.
“The typical ER is not well designed for psych patients,” Scott said. “It's designed for someone who’s having a heart attack or was in a car crash. If you place a psych patient in that same environment, they might find it frightening or claustrophobic or frustrating, which can lead to a lot of violence and agitation and aggression.”
That aggression can then cause a spiraling crisis. If the patient becomes a danger to themselves or others, the ER staff must restrain or even sedate them, trapping them even more restrictively in the stressful environment that is making the problem worse. This can then lead to the decision to transfer them to an inpatient psych ward, which might require waiting for days while the patient is strapped to a bed in the emergency department.
“It used to be that maybe one in 20 patients in the ER was there for a behavioral health reason. Now it's like one in eight,” Scott said. Clearly this system of treatment was not sustainable, but how do you take the stress and chaos of “emergency” out of an emergency department? Hospitals needed a solution to this paradox.
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EmPATH Units are that solution.
The published studies and official names and acronyms can make Scott’s EmPATH Units seem more complex than what they are – a physical space and mode of care that insulates patients from the distressing environment of the ER. Rather than treating the patient’s mental crisis as a secondary complication to be managed with brute force, they facilitate the ER staff treating the mental state of the patient as nearly as urgent a concern as the physical threat to their life.
To implement an EmPATH Unit, a hospital needs only to find, or create, a space in or near the emergency department where patients can be kept in a calm, quiet environment that allows them the freedom to see to their own basic needs. Maybe it’s a converted waiting room, a portion of the hospital chapel, or a temporary but comfortable shelter outside the building. Then ER staff are trained to send patients experiencing mental health crises to this space once they are confirmed as having been physically stabilized. There they can take their time as they are evaluated and treated by psychiatric professionals and, in most cases, allowed to leave after being successfully treated.
Scott’s research and professional experience showed that these patients need “a space where they're free to move about, where nobody was telling them, ‘go back to your room’ or ‘I'm calling security.’ They should be able to get themselves a snack or drink or blanket without having to beg a busy staff member,” Scott said. “Making things more comfortable, less disturbing and allowing people agency to decide what they want to do helps a lot to relieve agitation and aggression.”
“A lot” is modest at best.
“Before EmPATH, nearly 30 percent of patients in psychiatric crises at our ER went on to inpatient admission. After EmPATH, that number dropped to around eight to nine percent,” Marc Woods, chief nursing officer of University of Kentucky HealthCare Behavioral Health, began in a list of dramatic benefits seen since implementing their own EmPATH Unit in the summer of 2024.
“We’ve more than doubled the number of patients who connect to outpatient follow-up,” he continued, “rising from 29 percent before implementation to 65 percent now. About three-quarters of patients stabilize and are able to return home safely within roughly 16 hours, and 96 percent are diverted from state hospital placement.”
If drastically reducing the need to commit patients to psych wards wasn’t enough, Woods reported that “restraints and sitters (non-clinical staff who provide constant surveillance of patients) have been virtually eliminated.”
“Virtually eliminated” – an all-but unheard of result in the medical field. Thanks to their EmPATH Unit, for the past year and a half, nearly every patient at the University of Kentucky who might have been strapped to a bed for days, watched over nonstop by a stranger and sent to a hospital’s psych ward has instead been able to rest in a quiet, open room with a wall full of windows overlooking trees and grass until they are ready to go home. And more than double the previous number have chosen to seek non-emergency care afterward.
What gratitude and hope must the parents of a suicidal teenager feel at their family receiving this kind of care?
“I can’t publish this. This couldn’t possibly be true,” said the editor of the Western Journal of Emergency Medicine when Scott submitted the results of his original study for publication, according to Scott’s recollection. It showed the same kinds of outcomes now seen by the University of Kentucky and many other hospitals.
“No, really, it is!” Scott said.
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Today Scott is the vice president of acute psychiatry at Vituity, a healthcare firm headquartered in Emeryville, California, where he helps hospitals around the world implement their own EmPATH Units.
“There are more than 50 across the United States and Canada right now,” Scott said. “There are two that are going to be opening in Mexico in 2025. We estimate in the United States there will be more than 100 operating by 2027.” Locations in Europe, Australia and Singapore have also expressed interest.
The growth of the EmPATH method is remarkable for the cautious and skeptical world of health science, but the dramatic nature of the results begs the question: Why didn’t anyone think of this before? Wouldn’t it be obvious that agitated patients need a calm environment where they can collect themselves?
“I don’t think most ER doctors could imagine doing it differently than how they always had,” Scott said. By federal law, they must treat the medical emergency of everyone who comes to the hospital, mental health emergencies included, but most aren’t trained in emergency psychiatry. They naturally and rightly see the overdose, self-inflicted harm or other physical threat as the priority that they spent years training to handle according to incredibly strict procedures. The mental health emergency, however, was seen as a secondary complication that could be controlled by force.
Of course Scott has incredible respect for these physicians, but when it comes to this, “they tend to think ‘this is a nail and we have a hammer and that's how we do it.’”
Also, before the modern epidemic of mental health issues, there wasn’t necessarily a need to disrupt their process. An ER could send a patient to the psych ward soon after stabilizing the physical threat rather than waiting for days. Deciding how best to treat their psychiatric emergency wasn’t nearly as pressing as making sure the next patient didn’t die of a heart attack.
Which then begs the second and much more important question: Why is there such a massive crisis of mental health to begin with, especially in young people, and what can we do about it?
“That’s the million-dollar question,” Scott said. “If I knew the answer, I would have a Nobel Prize.”