Emergency departments across the United States serve as critical access points for individuals experiencing mental health crises, with visits for mental and behavioral health conditions representing a substantial and growing portion of emergency care. The traditional approach to mental health emergencies has often positioned law enforcement as the primary first responders, a practice rooted in historical deinstitutionalization efforts. This model has led to significant challenges, including high rates of involuntary psychiatric detentions that are costly, potentially traumatic, and sometimes clinically inappropriate. Recent research has examined alternative approaches, such as co-responder programs that pair mental health professionals with police officers, showing promise in reducing involuntary detentions while improving outcomes for individuals in crisis.
Current Landscape of Mental Health Emergency Department Visits
Local and state health departments, in collaboration with the CDC and various partners, collect and provide comprehensive data on emergency department visits related to mental health. This surveillance system has documented significant trends in mental health-related ED utilization, particularly among specific populations. Research indicates that mental health emergency visits have been increasing, with notable variations observed during the COVID-19 pandemic period. Studies have documented trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the pandemic, highlighting how public health crises can impact mental healthcare utilization patterns.
Among children and adolescents aged 5-17 years, seasonal trends in emergency department visits for mental and behavioral health conditions have been carefully tracked from January 2018 through June 2023. This longitudinal data has revealed important patterns in how mental health crises present in pediatric populations throughout the year, providing valuable insights for healthcare planning and resource allocation. The CDC maintains several dedicated resources addressing children's mental health, including specific guidance on treating children's mental health with therapy, anxiety and depression in children, behavior or conduct problems, obsessive-compulsive disorder, and post-traumatic stress disorder.
The collection and analysis of this data represent a critical public health function, enabling researchers and policymakers to understand the scope of mental health emergencies, identify emerging trends, and develop targeted interventions. By systematically tracking these visits, health authorities can better allocate resources, plan service delivery improvements, and evaluate the effectiveness of various approaches to mental health crisis response.
The Issue of Involuntary Psychiatric Detentions
Historical efforts to deinstitutionalize individuals experiencing mental illness in the United States have inadvertently positioned police officers as the typical first responders to emergency calls involving mental health crises. This arrangement has empowered law enforcement to initiate involuntary psychiatric detentions, a practice that, while potentially lifesaving in some instances, presents several significant challenges. Involuntary detentions are controversial due to their potential psychological impact on individuals, their high cost to healthcare systems, and concerns about their medical appropriateness in certain cases.
The process typically begins when police respond to mental health-related calls and determine that an individual poses a danger to themselves or others or is gravely disabled due to a mental disorder. This determination often leads to transportation to an emergency department, where medical personnel may further evaluate the individual and, in some cases, initiate the involuntary detention process. However, research suggests that this approach may not always align with the most appropriate healthcare response for individuals in crisis.
Studies have documented the substantial economic burden of involuntary psychiatric detentions. The initial emergency department visit alone, adjusted to 2022 US dollars, can range from $639 to $3,217, with the higher value often reflecting the extended "boarding time" experienced by individuals with mental illness waiting for appropriate placement. Additional costs emerge when detained individuals are admitted to inpatient care, with the daily cost of an inpatient stay for mental health or substance abuse issues averaging $1,365 in 2022 dollars. Given that as few as 25% of detainees are hospitalized, the expected 3-day hospitalization cost of a detention is approximately $1,024. When combined, these figures indicate that the direct cost of an involuntary psychiatric detention to emergency departments and hospitals varies from $1,663 to $4,241 in 2022 US dollars.
Beyond the financial considerations, involuntary detentions raise ethical and clinical concerns about the potential trauma experienced by individuals in crisis, the appropriateness of law enforcement involvement in mental health situations, and the potential for systemic biases in the detention process. These factors have motivated the exploration of alternative models for responding to mental health emergencies.
Co-Responder Program Model and Implementation
In response to the challenges associated with traditional police-only responses to mental health crises, many communities have begun implementing co-responder programs that pair mental health professionals with police officers as first responders to qualified emergency calls. This model represents a fundamental shift in how mental health emergencies are approached, aiming to provide more clinically appropriate responses while maintaining public safety.
The Community Wellness and Crisis Response Team (CWCRT) pilot program in San Mateo County, California, exemplifies this approach. The program operates on a theory of change that emphasizes the importance of having both clinical expertise and law enforcement authority present during crisis responses. Key implementation elements include:
- Establishing new protocols for the triage and communication of emergency calls
- Providing specialized training for dispatchers to identify appropriate calls for co-responder deployment
- Hiring appropriately trained mental health clinicians to work alongside police officers
- Ensuring the engaged participation of police officers in collaborative response efforts
- Building community awareness about the program and when to utilize it
The co-responder model recognizes that mental health crises often require clinical assessment and intervention capabilities that extend beyond traditional law enforcement training. By having mental health professionals directly involved in the initial response, the program aims to de-escalate situations, provide immediate assessment, and connect individuals with appropriate resources rather than defaulting to involuntary detention.
This approach requires careful coordination between multiple agencies and systems, including law enforcement, emergency medical services, healthcare providers, and community-based mental health services. The implementation process typically involves developing standardized procedures, conducting joint training sessions, and establishing clear communication channels between all parties involved in the crisis response system.
Effectiveness of Co-Responder Programs
Research examining the impact of co-responder programs has produced encouraging results regarding their ability to reduce involuntary psychiatric detentions. A study published in Nature Human Behaviour (2025) evaluated the effects of a co-responder program using two distinct quasi-experimental designs, providing robust evidence on the causal impacts of this intervention approach.
The first analysis examined the impact of the co-responder program on different types of emergency calls. Results indicated that the program led to a statistically significant reduction in emergency calls primarily related to mental health (b = −0.185, 95% CI −0.356 to −0.014, P = 0.0329). However, the program had statistically insignificant effects on the broader set of calls related to welfare checks and community disturbances, suggesting that its benefits may be most pronounced for mental health-specific crisis situations.
In the four pilot communities studied, 1,121 involuntary psychiatric detentions occurred in the 12 months before the CWCRT program implementation. The research indicates that 2 years of program operations lowered the number of such detentions by 370 (calculated as 1,121 × 0.165 × 2), representing a 16.5% reduction in involuntary psychiatric detentions (b = −0.180, 95% confidence interval −0.325 to −0.034).
The second analysis focused on binary indicators for the disposition of emergency calls identified by dispatchers as eligible for a co-responder response. This incident-level analysis provided evidence not only on the immediate impact of co-responders but also on whether their influence extends to reducing future incidents. The results suggested that the reduction in detentions reflected both a co-responder's influence on the disposition of an individual incident and a reduction in future mental health emergencies, indicating potentially longer-term benefits of the intervention.
Notably, the program had no detectable effect on program-related calls for service, criminal offenses, or arrests, suggesting that the co-responder approach can reduce involuntary detentions without compromising public safety or increasing other negative outcomes. This finding is particularly important as it addresses concerns that alternative response models might lead to increased crime or reduced law enforcement effectiveness.
Economic Impact and Cost Considerations
The implementation of co-responder programs carries significant economic implications that extend beyond the direct costs of operation. The reduction in involuntary psychiatric detentions achieved by these programs translates into substantial healthcare cost savings. Based on the estimated program-induced reduction of 185 involuntary psychiatric detentions per year, the annual health-cost savings range from roughly $300,000 to $800,000, calculated using the estimated direct costs of detentions ranging from $1,663 to $4,241 each.
These savings represent only the direct costs to emergency departments and hospitals and do not account for additional potential economic benefits, such as reduced utilization of other healthcare services, decreased involvement in the criminal justice system, or improved long-term outcomes for individuals with mental illness. The economic case for co-responder programs becomes even stronger when considering these broader system impacts.
However, it is important to note that implementing co-responder programs requires significant upfront investment, including hiring trained mental health professionals, providing specialized training for existing personnel, establishing new protocols, and creating infrastructure for effective collaboration between agencies. The cost-effectiveness of these programs depends on numerous factors, including program design, implementation fidelity, local healthcare costs, and the baseline rate of involuntary detentions in the community.
Despite these implementation costs, the economic evidence suggests that co-responder programs may represent a cost-effective approach to mental health crisis response, particularly in communities with high rates of involuntary psychiatric detentions. The potential for both improved clinical outcomes and reduced healthcare costs creates a compelling case for broader adoption of this model.
Limitations and Future Directions
While the research on co-responder programs provides encouraging evidence of their effectiveness, several important limitations must be acknowledged. The study examining the CWCRT program exhibits a high degree of internal validity due to the use of a preregistered research design and robust robustness checks. However, the researchers caution against overinterpreting the potential replicability of findings when applied to other contexts, highlighting limitations to external validity.
Several factors may influence the effectiveness of co-responder programs in different settings:
- Community demographics and characteristics
- Existing mental health infrastructure and resources
- Relationships between law enforcement and mental health providers
- Cultural factors influencing mental health help-seeking behaviors
- Local policies and procedures governing mental health crisis response
Successfully replicating and scaling promising evidence from early pilot programs like CWCRT likely hinges on attention to key design and implementation details. These include establishing appropriate protocols for triage and communication, ensuring adequate training for dispatchers, hiring qualified mental health clinicians, fostering genuine collaboration between police and mental health professionals, and building community awareness about available resources.
Future research should focus on identifying the optimal design elements for co-responder programs across different community contexts, examining long-term outcomes for individuals who receive co-responder interventions, and evaluating the cost-effectiveness of these programs in diverse settings. Additionally, research should explore how co-responder models can be integrated with other crisis response innovations, such as mobile crisis teams and crisis stabilization centers, to create more comprehensive systems of care.
Conclusion
The traditional approach to mental health emergencies, which relies primarily on law enforcement as first responders, has led to high rates of involuntary psychiatric detentions that are costly, potentially traumatic, and not always clinically appropriate. Co-responder programs that pair mental health professionals with police officers offer a promising alternative, with research demonstrating a 16.5% reduction in involuntary psychiatric detentions without compromising public safety or increasing other negative outcomes.
The implementation of these programs requires careful attention to design and execution, including establishing appropriate protocols, training personnel, ensuring collaboration between agencies, and building community awareness. While the upfront costs of implementation can be substantial, the potential healthcare cost savings and improved clinical outcomes suggest that co-responder programs may represent a cost-effective approach to mental health crisis response.
As communities continue to grapple with the challenges of providing appropriate care for individuals experiencing mental health crises, the evidence supporting co-responder programs provides motivation for continued innovation and evaluation. By refining these models based on emerging research and adapting them to local contexts, stakeholders have the opportunity to create more compassionate, effective, and efficient systems of crisis care that better serve individuals experiencing mental health emergencies.