Mental Health in the ED

Author: Tess Dick / Editor: Charlotte Davies / Codes: CAP30 / Published: 09/10/2018

Over the years I have toyed with the idea of writing about my views on how Mental Health conditions are treated in the Emergency Department (ED). I have recently been inspired to put pen to paper by RCEM’s Mental Health Toolkit whose introduction states:
“The core principle of Mental Health in the Emergency Department: A patient presenting to ED with either a physical or mental health need should have access to ED staff that understand and can address their condition”.

As a doctor that has previously struggled with my Mental Health I hope to try and help promote a greater understanding amongst ED staff by sharing some of my experiences, and by talking through the recommendations in the Toolkit. Mental Health problems are a common presenting issue for patients attending the ED; one Consultant Psychiatrist even said that we see more mental health patients than the psychiatrists so it’s important we feel confident in how to manage it. It’s important to remember that mental health presentations aren’t just those who present with “overdose” – they’re the lonely 70 year old with chest pain, the anxious 30 year old with asthma, the somatising chronic pain patient. They’re all important and we are privileged enough to look after them all!

I think it’s most doctors worst nightmare to think a patient may abscond or be discharged and then harm themselves again after presenting to the ED. The Toolkit gives a set of recommendations for what to cover when assessing a patient presenting with a Mental Health problem; the recommendations reassure us that we have covered the important things and that our management decisions are justified:

  • Physical needs should be promptly met
  • Mental Health history (see box 1). This is something we document only 50% of the time, and it covers information that Mental Health teams are interested in knowing when we refer.
  • Risk assessment e.g. Pierce suicidal intent score. This can help us decide if a patient is a high risk of harming themselves again, it helps justify discharge with a plan for the GP to follow-up, and it clarifies if we need the Mental Health team to assess a patient prior to them leaving. Find out which risk assessment tool your department uses.
  • Mental Capacity assessment gives us information on whether a patient has the ability to make decisions against medical advice. This group of patients are more likely to want to leave before treatment is complete and we need to be able to document whether they can process the information we give in order to make a competent decision. If they are not able to make a competent decision we may need the help of security, or 1 to 1 nursing to keep the patient safe.

Although it is good to have a checklist of what to cover, it can take an enormous amount of time in order to get the information that the Toolkit recommends. When under time pressure it can feel like these recommendations are unrealistic. But then I remember the time I saw a patient return multiple times with Paracetamol overdoses who was hell-bent on committing suicide. She needed a lot of encouragement to agree to treatment for her overdose as she had capacity to refuse treatment. If I hadn’t spent the time to understand why she took the overdose, I wouldn’t have discovered the relative that had sexually abused her as a child was due to be released from prison, which had made her suicidal. She had grown up in foster care so was institutionalised; she wanted to be in hospital when she died as she felt safe there so would present to hospital after she’d overdosed. Finding out this information meant we could provide her with support and inform the Mental Health team why she was continuing to need help.

I get that when working hard and seeing waiting times rise in the department we might question whether this is the right place to manage these patients, but ED staffing and skill mix usually means we can provide higher doses of sedation to agitated patients than can be provided elsewhere, can manage both the physical and mental issues these patients present with, and we are open 24/7 unlike other services. Sadly, this frustration can compromise our ability to empathise.

As a doctor that has personal experience of Mental Health problems I agree wholeheartedly with the sentiment in which the Mental Health Toolkit is written, encouraging healthcare staff to be more open about Mental Health and to show empathy and understanding. My experience as a patient taught me that a balance between empathy and straight-talking helped me open up and engage with treatment. The repercussions of poor communication with patients who are already feeling emotionally unstable can be more explosive. As an example I can remember a patient brought to my department under a section 136: he was a young guy who had been found on the railway track attempting suicide. He was agitated, violent towards staff and himself, and he was easily provoked. He had been seen at another department and had input from both the Mental Health Team and the ED staff and had been discharged due to his behaviour. The police still had concerns that the patient was a danger to himself and others, so they brought him to our department. He was angry because of his desperation; all he wanted to do was commit suicide and we were stopping him from doing what he wanted. Having been suicidal myself I can understand why he was so volatile; it is a thought that consumes you – you can get lost in plans of how to achieve it, and if it doesn’t work out it can feel that all your hopes of a solution to your problems have been taken away. After a time he calmed down enough for us to reason with him and he engaged with the Mental Health team, and he ultimately agreed to a voluntary admission.

Mental Health patients are at high risk of absconding or not waiting to be seen. This can risk missing an opportunity to manage a vulnerable person who may come to further harm. I really like the importance the Mental Health Toolkit places on taking every opportunity to offer patient support, recommending the supply of a leaflet “Feeling on the Edge” to every self-harm patient at triage and suggesting educating patients on the existence of community-based support networks like the Liverpool Light caf where they may seek help if they don’t feel they need help urgently. When I had struggled with depression I often felt guilty telling people about my difficulties as I didn’t understand why I couldn’t manage my emotions myself. Taking every opportunity to show that it’s OK to find life hard, and that there is support out there reassures and the leaflet Feeling on the Edge is thought to reduce the number of patients who do not wait in the ED.

Generally, I think us healthcare professionals are an understanding and open-minded bunch, but sometimes I think we forget ourselves. I was a teenager that self-harmed. I didn’t think about how it would affect people’s impression of me when I was older, but now I’m a doctor, I do feel a certain stigma attached to being someone that has previously self-harmed. In fact, as a medical student I was told by a fellow student that people who have had Mental Health problems in the past shouldn’t be doctors as they wouldn’t have the mental strength to work as a doctor. I can understand why people might think that as I did have an unhealthy coping strategy for stress at that point. The therapy I had helped me reflect on experiences and learn from them, which built up a resilience that I wouldn’t have had without it. Now, I’m not saying that I have some sort of superpower because I’ve had therapy and others haven’t, so somehow I’m better. Resilience is something that people develop in different ways but I do feel more in touch with my emotions and how my thought processes contribute to how I feel and act which helps me work on how to cope in times of stress and sadness. I think that has made me a stronger person.

So I guess my take-home message from this blog is to encourage everyone to have a structure when they speak to patients with Mental Health problems so they know they have covered all the bases, whether that’s in the form of a proforma (which is what the Toolkit suggests) or in their head; to be mindful of how they communicate, especially with patients who are more emotionally vulnerable even if they are presenting in an aggressive way; and when talking about Mental Health, be aware that 1 in 4 people experience a Mental Health problem each year and an atmosphere of openness and understanding will help people come forward, talk about it and deal with it better.

References and Further Reading:

  1. RCEM Toolkit
  2. NCEPOD Report
  3. RCPsych – feeling on the edge leaflet
  4. Capacity SAQ
  5. The MCA – a podcast
  6. Explored MCA Cases
  7. Psychiatric Emergencies – RCEM Member Benefit – Learning Module

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