• mental health, assessment
• mental health
• mental health, management

Emergency mental health is part of our core business, although emergency department (ED) staff may have varying levels of comfort with this. We need to be as competent with the initial management of a patient with a mental health crisis as we are with trauma, sepsis or any other emergency. To do this, we need compassion and empathy underpinned by systems and training for all our staff. Our attitudes to patients in crisis are often the key to improvements in care. If we are honest, some ED staff are fearful and worry that what they say may make a patient feel worse. Others may resent patients who come repeatedly in crisis. It helps to consider these patients just as we would patients with asthma or diabetes who may also come ‘in crisis’. Our role is to help get them through that crisis, with kindness and competence.

A detailed look at Hospital Episode Statistics (HES) for England 2013/2014 by Baracaia et al in EMJ show that 4.9% of all ED attendances were coded as having a primary mental health diagnosis.1 Cumulative HES data have shown an average increase in mental health attendances of 11% per year since 20132 (figure 1) far in excess of total ED attendance increase (figure 2). National data from the USA show a 40.8% increase in ED visits for adult with a mental health presentation from 2009 to 2015.3 US paediatric visits for the same period rose by 56.5%3 and a worrying 2.5-fold increase over 3 years in the USA is reported for adolescents ED visits identified as related to suicide.4

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Figure 1

Number of UK ED attendances with Psychiatric condition as primary diagnosis 2009/10-2017/18

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Figure 2

Total number of UK ED attendances 2009/10-2017/18

There are many possible reasons for this increase, it is hard to separate out a possible increase in mental illness from a decrease in stigma and increased perceived urgency to get help. Lack of funding and investment in mental health services seems to be universal. This is the most acute in child and adolescent services who have had the greatest rise in demand. Where this happens in any system, there is a knock-on effect of increased ED attendances.

Baracaia et al quantify what ED clinicians experience; that two-thirds of mental health attendances occur out of hours. Often this is because EDs are the only places open. More recently in the UK, there has been the introduction of crisis cafes and telephone lines run by NHS services. NHS England has pledged to provide access to mental health services via the NHS emergency phoneline 111 by 2023/2024.5 EDs in the future should work with providers to create pathways for patients who have no physical health needs to use these services.

Of great concern is the long waits many patients have in EDs not only for assessment but for inpatient mental health beds. This undoubtedly causes some patients to deteriorate, causing increasing agitation, potential for self-harm and need for restraint and rapid tranquilisation.6 Part of our role as leaders in emergency medicine is to keep challenging the system, calling for increasing investment not just in crisis care and mental health beds but in community services that can respond pre-crisis.

Baracaia et al also show that one-third of all attendances required acute hospital admission, which indicates that many patients need physical as well as mental healthcare, (although some patients may be admitted due to delays in psychiatric assessment or accessing a mental health bed.) Ideally, physical and mental health care and assessment work in parallel. This requires well-staffed 24/7 mental health teams, good communication and joint working between ED and mental health teams. There is national pressure in the UK to be rid of the practice in some places of waiting for a patient to be ‘medically cleared’ before mental health professionals will assess a patient. A joint Royal Colleges statement has been released calling for physical and mental healthcare teams to work ‘Side by Side’.7

A key priority for patients presenting to the ED in mental health crisis is safety. It is a concern if a patient leaves our ED without being assessed or getting the help they need and distressing for all if a patient self-harms while in our care. A system of mental health triage is needed to identify patients most at risk of absconding or self-harm. When done well, this facilitates nursing staff to engage with the patient on arrival and offer help and support. A second paper in EMJ by Mackway-Jones has used a Delphi method to produce a mental health triage for patients presenting in crisis to the ED . Theirs is the first triage system produced by experts in this way and includes assessment of risk of absconding as well as severity of presentation.8

Mental health triage was a focus of a recent UK Healthcare Safety Investigation Branch (HSIB) investigation where the index case was a woman who had attended an ED four times with self-harm and had left twice without being seen by mental health services. She tragically took her life 4 days after the last attendance. One of HSIB’s recommendations was for standardisation of the initial assessment of patients coming to the ED in crisis. No mental health triage system has been properly validated, and while many departments have well-functioning, embedded systems, others will need to introduce triage and training for their department.9 Mental health triage is only as good as the response made to the assessment. This may be for an emergency clinician to see a patient urgently, it may require close observation of that patient and clearly requires timely assessment of the patient by mental health teams. Mental health is one the RCEM National Quality Improvement Projects this year and includes documentation of observations for patients that are identified as being high risk. We should go further on this and ask for advice and training from our mental health colleagues as to how to make these observations as least restrictive and as therapeutic as possible.

Mental health triage should not be used as a suicide risk assessment tool. Suicide risk stratification methods are fraught with difficulty.10 Around half of all suicides are in people who would have been deemed low risk and of those thought to be high risk, 5% will die by suicide but over the long term.11 Without a useful suicide risk assessment tool, clinicians instead need to engage with the individual person in crisis, consider their current needs and work with them and other professionals to help meet those needs.

While a full psychosocial assessment is the realm of mental health professionals, ED clinicians need to be competent and comfortable to do a brief risk assessment in order to keep patients safe. Patients detect when we are not comfortable talking about mental health and this may lead to more stigma and guilt, whereas an ability to listen to a patient’s story and be empathetic is therapeutic. Most emergency medicine curricula and assessments now include mental health. However, the best training often comes from the mental health teams we work with, both regular, formal training for all ED staff and debrief of situations which were challenging to manage. We can also learn a huge amount from listening to patients’ experiences in our departments and should consider how to find out what our patients think.

All this may not be as exciting as managing trauma or sepsis but undoubtedly saves lives.