Emergency department (ED) visits for psychiatric complaints are increasingly common. The 1% to 3% of ED patients who screen positive for suicidal ideation comprise a population at heightened risk of completing suicide.1,2 While emergency psychiatric presentations are often associated with serious mental illness, patients of all acuity levels present in this setting. The most common psychiatric presentations in the ED are for anxiety, depression, or stress reactions.3
Providing treatment to these patients in the ED introduces complexity of care that emergency psychiatrists are attempting to address with a mix of service delivery models. This article discusses the peculiarities of emergency psychiatric practice and reviews innovations in models of care delivery designed to overcome the challenges of this subspecialty.
A difficult place to provide good care
The growth of psychiatric care in ED settings is driven by several factors. Foremost is a trend towards treating sicker patients in less restrictive care environments. Increasingly, patients with significant psychiatric disease are being treated in outpatient and integrated care environments. At the same time, long-term inpatient and residential treatment has become scarcer.4 Thus, EDs become the backstop for highly acute patients who present with suicidality, violent thoughts, intoxication, and/or acute psychosis. Other factors driving this trend towards less restrictive treatments include financial incentives and the ready accessibility of emergency care compared with the limited availability of community mental health facilities. Also driving the trend toward acute care in the ED is the American epidemic of psychiatric illnesses, particularly substance use disorders, that are associated with increased use of emergency services.5
Delivering psychiatric care in the ED is not easy. Most emergency medicine providers feel comfortable managing common psychiatric presentations, however, their expertise does not always extend to managing sicker patients or those requiring more nuanced psychiatric assessments—for example, patients with personality disorders and chronic suicidal ideation, or patients with schizophrenia whose ability to care for themselves is called into question.
Patients with psychiatric illness frequently have undertreated medical illness that requires attention and care coordination. Delirium is commonly missed among ED patients, and longer ED stays are associated with an increasing risk of incident delirium.6 Frequent changes of staff, lack of specialty consultants, constant sensory stimulation, and ill-suited infrastructure all render EDs a challenging environment in which to deliver care for patients in psychiatric crisis. Table 1 summarizes these and other clinical challenges unique to the field of emergency psychiatry.
Dr Simpson is Medical Director, Psychiatric Emergency Services, Denver Health Medical Center.
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