Emergency Care and Mental Health

When we’re faced with an urgent health concern, whether it’s a broken bone or a sudden heart attack, we typically make a trip to the emergency department (ED).

Many countries advise people to seek the ED for mental health crises, and the number of people admitting for these reasons is substantial and continues to increase.

In the United States, between 2009 and 2015, there was a 40.8% increase in mental health cases in the ED, which represented more than 10% of all ED cases among individuals aged 15-64 (Santillanes et al., 2020). In 2004/5, the number of mental health cases accounted for 3.2 per cent out of all ED cases in Australia (AIHW, 2007), which rose to 3.6 per cent of cases in 2016/7 (AIHW, 2018).

Reflecting on a Systematic Review

Bull et al. (2024), affiliated with the Greater Brisbane Clinical School in Queensland, Australia, examined the experiences of mental health patients admitted to the ED. Their systematic review is titled “Experiences of individuals presenting to the emergency department for mental health reasons: A systematic mixed studies review”, and published in Australian & New Zealand Journal of Psychiatry.

Using Pluye and Hong’s (2014) comprehensive systematic mixed studies review (SMSR) method, Bull et al. (2024) examine experiences across multiple countries and insightfully address a gap in research on a topic that has received surprisingly little attention, despite the high prevalence of mental health-related ED visits worldwide.

Bull et al. (2024) structure their research article in a standard format—introduction, methods, results, and discussion. In the methods section, they provide their step-by-step application of Pluye and Hong’s (2014) seven-step approach to SMSR. A brief summary is as follows:

The authors follow strict eligibility criteria for study inclusion, ensuring a comprehensive review of relevant literature. Search terms centred on key concepts of mental health ED cases —“patient experience,” “mental health,” and “emergency department”, which were used to retrieve studies from electronic databases. Eligible studies came from the US, Canada, and Australia. A qualitative thematic approach was used to extract common themes across the studies.

From the qualitative themes that emerged, the study found that the primary factor influencing the experiences of individuals admitted for mental health reasons was their interactions with ED staff. These interactions were categorised as either positive or negative.

• Patients felt positively about interactions with mental health specialists and peer recovery workers, as it made patients feel understood, cared for, and hopeful about recovery.
• Patients felt positively about judgment-free interactions and reassurance that it’s okay to seek help from ED.
• Patients felt positively about receiving physical and psychological support sensitive to mental health needs. This included asking before doing things that can be triggering for some people (e.g., taking blood, rolling up sleeves because of scars showing, and whether the patient was comfortable talking to a doctor of the opposite sex).

• Patients felt negatively about the invalidation of getting ED care for their mental health issues. The dismissal of their suicide or self-harm attempts led patients to believe that next time they needed a more fatal outcome to convey the seriousness of their issues.

The authors’ use of the systematic mixed studies review approach is a notable strength, allowing them to provide an understanding of patient experiences while drawing on both qualitative and quantitative studies. Their clear, structured methodology—including strict eligibility criteria and thoughtful use of search terms—demonstrates a rigorous approach. Furthermore, by applying the Mixed Methods Appraisal Tool (MMAT) developed by Pluye and Hong (2014), the authors ensure a high level of reliability in their evaluation of the included studies   (Pace et al., 2012).

While the study provides important insights, there are challenges in generalising the findings, as ED experiences vary significantly across different countries. Healthcare systems, cultural perceptions of mental health, economic resources, and legal frameworks differ internationally, meaning that the experiences of mental health patients in EDs in countries like Australia, the United States, or Canada may not apply to other regions. It is even debatable whether the experiences across these countries are similar enough to be reviewed together. This raises the question of whether systematic reviews of studies across different countries are the most appropriate approach for studying patients’ experiences in EDs.

Key Takeaways

Overall, Bull et al. (2024) offer an insightful contribution to understanding the experiences of mental health patients in EDs. The article highlights the need for systemic improvements, particularly in how staff engage with mental health patients. While there are challenges related to generalisation and cross-cultural applicability, the study makes a significant contribution to the literature and offers a path forward for improving mental health care in ED settings globally.