Marc Sabbe discusses the evolution of emergency psychiatry, highlighting issues such as deinstitutionalisation and cost containment.
There is no doubt that the amount and intensity of stress factors have increased over time in our society. Burn out is an actual and hot topic, and employers search for measures for their employees to prevent it as much as possible. Life speeds up, and there is increasingly less time to de-stress.
On top of the risk of burn out, persons at risk for a psychiatric disorder are also under the influence of these same stress factors and thus have a greater chance to further develop a psychiatric disorder or to relapse. Thus, the number of patients needing mental health care increases significantly. In addition, over the last two decades, the organisation and provision of mental health care has changed dramatically. The two most important shifts that can be detected are the deinstitutionalisation of mental health services and the governmental efforts of cost containment.1
Firstly, deinstitutionalisation has resulted in a decrease in the number of psychiatric beds available, as well as in a decrease in the average length of stay in psychiatric hospitals. A particular consequence of this is that the number of psychiatric patients with a severe mental illness living in the community instead of living in an institution has increased. This results in a significant number of patients facing difficult challenges or adaptation when discharged from a psychiatric hospital.
In addition, if a psychiatric crises occurs in this specific population, limited opportunities exist for immediate acute mental health care or an acute readmission to a psychiatric hospital. This rapid transition to community care has also highlighted some existing gaps not only in the co-ordination of outpatient services, but also in treatment protocols or strategies. Especially during out of hours, the emergency department (ED) remains the only medical facility for immediate psychiatric care. And if emergency psychiatry is not well implemented in the structures of the ED, then the ED only serves as a psychiatric holding capacity and gate keeper.
Efforts of cost containment have also modified the mental health care system. Cut backs in funding were often promoted as a need towards a more rational, efficient, and scientific evidence-based utilisation of limited resources. The increasing needs of well organised continuous acute mental health care makes cost containment quite difficult.
Following this, emergency departments have observed an increase in psychiatric emergency referrals. Year after year, the increase of psychiatric patients in the ED has always been significantly higher than the average yearly percentage of increase of all ED patients. In particular, the increase of young adolescents (14-18 year old) with psychiatric problems in the ED is alarming.
But what are the most frequent presenting complaints of psychiatric patients coming to or referred to the ED? Suicidality remains the most common presenting complaint, followed by depressed mood, substance abuse (specifically alcohol abuse), anxious mood, delusions and hallucinations. In contrast, persons with emotional problems seem more likely to seek mental health care in general medicine facilities. More than 50% of patients looking for mental health care in the ED have a history of at least one psychiatric hospitalisation and one in three have a previous referral to the ED for acute psychiatric care.2
Recurrent users are more likely to have personality disorders and use the ED as an additional treatment facility since they already utilise inpatient or outpatient services. In contrast, of those visiting the ED for the first time seeking for psychiatric care, however, half did not have any contact with any inpatient nor outpatient mental health care in the past. For those, the ED is clearly the entry point into specialised mental health care. In conclusion, a large variety of persons and complaints can be detected.
In the start-up period of emergency psychiatry, the initial task in the ED was to triage those patients as soon as possible away to more appropriate psychiatric treatment setting. Thus, the ED served as an easily accessible step up into more specialised mental health care. However, an ED is mainly considered and designed to take care of patients with an acute trauma or illness. At first glance, the psychiatric patient has no clear place in the ED, except if the patient is admitted with an intentional poisoning or if a medical clearance needs to be performed, meaning that a diagnostic work-up is needed to exclude a somatic disease that could explain the potentially psychiatric symptoms.
Acute psychiatric care, however, has developed and adapted to the progressive change of clinical profiles, as patients attending the ED with psychiatric complaints demonstrate a huge diversity in demographic and clinical characteristics.
The evolution of emergency psychiatry
The first stage in this evolution saw some psychiatrists become interested in and focused on the existing and growing population demanding acute mental health care. The development of Emergency psychiatry with specific screening and treatment approaches to accurately detect and treat acute mental illness was the normal next step. But psychiatrists working mainly in the ED remain a minority. Secondly, the fragmented mental health care needed more organisation and co-ordination. Setting up better collaborations with primary care, community-based mental health facilities or specialised care in a locoregional mental health care network results in a more appropriate and effective continual mental health care.3
Although the establishment of psychiatric networks may be a good response to the lack of well-organised psychiatric emergency care, their implementation will remain relatively suboptimal if they are not integrated in the policy making or strategic planning of the ED. It is therefore necessary for general hospitals to punctuate the role of emergency psychiatry in their mission statement.
In addition, the necessary financial support is needed to establish the above mentioned steps in favour of being capable to provide appropriate acute mental health care within such networks. The recent development of reach-out teams, visiting the patient at home shortly following their contact with emergency psychiatry, is closing the continuity of care circle.
One can thus conclude that positive evolutions can be detected in the construction of appropriate acute mental health care where the ED plays an important gate keeper role. However, these efforts should be implemented in such a way that the whole population of a region or country is covered.
Mental health care is not the sexiest part of medicine, but it is extremely necessary in our society, which is always demanding more. Cost containment is only possible if the efficacy of the global acute mental health care is preserved.
- Bruffaerts R, Sabbe M and Demyttenaere K. Attenders of a university hospital psychiatric emergency service in Belgium. General characteristics and gender differences. Soc Psychiatry Psychiatr Epidemiol 39: 146-153, 2004.
- Bruffaerts R, Sabbe M and Demyttenaere K. Who visits the psychiatric emergency room for the first time? Soc Psychiatry Psychiatr Epidemiol 41: 580-586, 2006.
- Bruffaerts R, Sabbe M and Demyttenaere K. Emergency psychiatry in the 21th century: critical issues for the future. EJEM 15: 276-278, 2008.
Emergency Medicine – KU Leuven
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This is a commercial article that will appear in Health Europa Quarterly issue 6, which will be published in August, 2018.