Review article: Interventions for people presenting to emergency departments with a mental health problem: A systematic scoping review

I have not come here because I have nothing better to do: The lived experience of presenting to the emergency department for people with a psychosocial disability and an NDIS plan-A qualitative study

Almost 60 000 people have a psychosocial disability (PSD) and a National Disability Insurance Scheme (NDIS) plan. As PSD can be a fluctuating condition, people with a PSD and an NDIS plan, at times, may require crisis care and present to the emergency department (ED). This national study explored the experiences of people with a PSD and an NDIS plan when presenting to the ED. To understand the unique lived experience of people with a PSD and an NDIS plan, semi-structured interviews were conducted with 24 people between March and November 2022 and were analysed thematically. A lived experience advisory group was engaged as part of the research team. Participants were asked about their experiences in the ED including barriers to therapeutic care and what worked well. Participants reported emotional distress caused by receiving a biomedical rather than a person-centred mental health response. A previous mental health history overshadowed diagnostic decisions and most participants interviewed stated they would not choose to return to the ED. Half of the participants spoke of one presentation only where needs were met. Four main themes emerged from the data: (a) Diagnostic overshadowing; (b) Judgement and stigma; (c) Waiting without hope; and (d) If things went well. This study provides evidence of the unique lived experience of people with a PSD and an NDIS plan when presenting to the ED. The results highlight the need for clinicians in the ED to understand the complexity and nuances of supporting people with a PSD. Recommendations for a person-centred care approach are provided. Alternative support options for this group of people need to be explored.

The effectiveness of brief non-pharmacological interventions in emergency departments and psychiatric inpatient units for people in crisis: A systematic review and narrative synthesis

OBJECTIVE

Heterogeneous brief non-pharmacological interventions and guidelines exist to treat the burgeoning presentations to both emergency department and inpatient settings, for those in a crisis of mental ill-health. We systematically reviewed the literature to create a taxonomy of these brief non-pharmacological interventions, and review their evaluation methods and effectiveness.

METHOD

We conducted a systematic review across Cochrane, CINAHL, DARE, Embase, MEDLINE, PsycINFO databases. Studies meeting quality criteria, using Joanna Briggs Institute tools, were eligible. Interventions were categorised, and outcomes synthesised.

RESULTS

Thirty-nine studies were included: 8 randomised controlled trials, 17 quasi-experimental, 11 qualitative studies, and 3 file audits. Taxonomy produced six coherent intervention types: Skills-focussed, Environment-focussed, Special Observation, Psychoeducation, Multicomponent Group and Multicomponent Individual. Despite this, a broad and inconsistent range of outcome measures reflected different outcome priorities and prevented systematic comparison of different types of intervention or meta-analysis. Few brief non-pharmacological interventions had consistent evidential support: sensory modulation rooms consistently improved distress in inpatient settings. Short admissions may reduce suicide attempts and readmission, if accompanied by psychotherapy. Suicide-specific interventions in emergency departments may improve depressive symptoms, but not suicide attempt rates. There was evidence that brief non-pharmacological interventions did not reduce incidence of self-harm on inpatient wards. We found no evidence for frequently used interventions such as no-suicide contracting, special observation or inpatient self-harm interventions.

CONCLUSION

Categorising brief non-pharmacological interventions is feasible, but an evidence base for many is severely limited if not missing. Even when there is evidence, the inconsistency in outcomes often precludes clinicians from making inferences, although some interventions show promise.

Improving emergency department care for adults presenting with mental illness: a systematic review of strategies and their impact on outcomes, experience, and performance

Background

Care delivery for the increasing number of people presenting at hospital emergency departments (EDs) with mental illness is a challenging issue. This review aimed to synthesise the research evidence associated with strategies used to improve ED care delivery outcomes, experience, and performance for adults presenting with mental illness.

Method

We systematically reviewed the evidence regarding the effects of ED-based interventions for mental illness on patient outcomes, patient experience, and system performance, using a comprehensive search strategy designed to identify published empirical studies. Systematic searches in Scopus, Ovid Embase, CINAHL, and Medline were conducted in September 2023 (from inception; review protocol was prospectively registered in Prospero CRD42023466062). Eligibility criteria were as follows: (1) primary research study, published in English; and (2) (a) reported an implemented model of care or system change within the hospital ED context, (b) focused on adult mental illness presentations, and (c) evaluated system performance, patient outcomes, patient experience, or staff experience. Pairs of reviewers independently assessed study titles, abstracts, and full texts according to pre-established inclusion criteria with discrepancies resolved by a third reviewer. Independent reviewers extracted data from the included papers using Covidence (2023), and the quality of included studies was assessed using the Joanna Briggs Institute suite of critical appraisal tools.

Results

A narrative synthesis was performed on the included 46 studies, comprising pre-post (n = 23), quasi-experimental (n = 6), descriptive (n = 6), randomised controlled trial (RCT; n = 3), cohort (n = 2), cross-sectional (n = 2), qualitative (n = 2), realist evaluation (n = 1), and time series analysis studies (n = 1). Eleven articles focused on presentations related to substance use disorder presentation, 9 focused on suicide and deliberate self-harm presentations, and 26 reported mental illness presentations in general. Strategies reported include models of care (e.g., ED-initiated Medications for Opioid Use Disorder, ED-initiated social support, and deliberate self-harm), decision support tools, discharge and transfer refinements, case management, adjustments to liaison psychiatry services, telepsychiatry, changes to roles and rostering, environmental changes (e.g., specialised units within the ED), education, creation of multidisciplinary teams, and care standardisations. System performance measures were reported in 33 studies (72%), with fewer studies reporting measures of patient outcomes (n = 19, 41%), patient experience (n = 10, 22%), or staff experience (n = 14, 30%). Few interventions reported outcomes across all four domains. Heterogeneity in study samples, strategies, and evaluated outcomes makes adopting existing strategies challenging.

Conclusion

Care for mental illness is complex, particularly in the emergency setting. Strategies to provide care must align ED system goals with patient goals and staff experience.

'Everything would have gone a lot better if someone had listened to me': A nationwide study of emergency department contact by people with a psychosocial disability and a National Disability Insurance Scheme plan

Australians with a psychosocial disability (PSD) and a National Disability Insurance Scheme (NDIS) plan may at times require emergency care due to the fluctuating nature of their physical and mental health conditions or when their supports have become insufficient. This nationwide study investigated the experiences of people presenting to an emergency department (ED) who have a PSD and an NDIS plan. The objective was to understand current care and communication practices and to provide recommendations for service integration. Twenty-four interviews were conducted with people who had a PSD and an NDIS plan. Participants were asked semi-structured questions about their experiences when engaging with NDIS processes and when engaging with the ED as an NDIS recipient and how communication practices could be improved between the two services. A qualitative, descriptive thematic analysis approach was used. A lived experience advisory group participated in the research and provided commentary. The findings of this study indicate that the NDIS, as a personalised budget scheme, presents challenges for people with complex PSD and physical needs. ED clinicians appear to be unclear about what the NDIS provides and communication between the two systems is fragmented and inconsistent. The themes identified from the analysed transcripts are: (a) People with PSD experience distress when dealing with the NDIS; (b) There's a blame game between the ED and the NDIS; and (c) Inadequate service integration between the ED and NDIS. Recommendations to assist with service integration include building service capacity, providing overlapping care and bridging the diverse biomedical, psychosocial and disability care services.

Effectiveness of emergency department based interventions for frequent users with mental health issues: A systematic review

Frequent emergency department (ED) users with mental health issues are particularly vulnerable patients, who often receive insufficient or inadequate outpatient care. This systematic review identified and evaluated studies on ED-based interventions to reduce acute care use by this population, while improving outpatient service use and patient outcomes. Searches were conducted in five databases for studies published between January 1, 2000, and April 30, 2022. Eligibility criteria included: patients with mental health issues who made 2+ ED visits in the previous 6 months or were high ED users (3+ visits/year), and who received ED-based interventions to reduce ED use. The review included 12 studies of 11,082 articles screened. Four intervention groups were identified: care plan (n = 4), case management (n = 4), peer-support (n = 2) and brief interventions (n = 2). The definitions of frequent users varied considerably, while the quality assessment rated studies from moderate to good and risk of bias from low to high. Eight studies used pre-post design, and four were randomized controlled trials. Ten studies assessed outcomes related to use of other services than ED, mainly hospitalizations, while five assessed patients' clinical conditions and three, social conditions (e.g., housing status). This review revealed that case management and care plan interventions, based in ED, decrease ED use among frequent users, while case management also showed promising results for outpatient service use and clinical and social outcomes. Thus, the results support continued deployment of intensive ED-based interventions for frequent ED users with mental health issues although firm conclusions regarding the effectiveness of these interventions, particularly outcomes related to services other than ED, require further investigation.

People brought to the emergency department under involuntary assessment orders: A scoping review

BACKGROUND

Some people with mental health problems arrive to the Emergency Department (ED) under involuntary assessment orders (IAOs) and can have complex medical and socioeconomic factors, which may impact on the delivery of care in the ED. Therefore, this scoping review aimed to identify, evaluate and summarise the current literature regarding the demographic characteristics, clinical characteristics and outcomes for people brought to the ED under IAOs.

METHOD

A scoping review was undertaken guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Guidelines and the Arksey and O'Malley framework.

RESULTS

In total 21 articles were included in this review. People under IAOs most commonly present to EDs with suicidal ideation/intent, with interagency involvement noted when responding to these people in the pre-hospital setting. Most people arriving to ED under IAOs were reported to experience length of staylonger than four hours.

CONCLUSION

This review highlights the limited information pertaining to people brought to EDs under an IAO. High levels of mental health problems and extended length of stay for people under IAOs suggests the need for interagency collaboration to inform the development and implementation of models of care that incorporates social determinants of health and are tailored to this complex population.

The NSW Emergency Psychiatry Network

Emergency Psychiatry is evolving. In an environment that lacks a clear evidence base, and where a constellation of factors is driving up Emergency Department presentation rates and lengths of stay, several stakeholders are working towards and clamouring for change. With the goal of collaborating with such parties, we believe Emergency Psychiatrists should position themselves to establish and advocate for best-practice change in culture, research, clinical care and training, and funding in the provision of mental health crisis care. To this end, we have formed the NSW Emergency Psychiatry Network, a group of Emergency Psychiatrists with a broad experience in a range of settings, from tertiary metropolitan emergency facilities with access to subspecialty psychiatric services, to rural and remote emergency settings with sporadic in-reach from local mental health services and telehealth. We unanimously recognise the need to upskill both Emergency Department and Mental Health clinicians in crisis care, and the need for committed, evidence-based Mental Health resourcing within Emergency Departments.

Communication pathways from the emergency department to community mental health services: A systematic review

This systematic review synthesizes existing peer reviewed evidence reporting on evaluated strategies used for enhancing communication pathways for continuity of care between the emergency department and mental health community supports. Following the PRISMA guidelines and the PICO framework, this review was conducted between January and July 2021. Included articles needed to evaluate communication pathway interventions for continuity of care between the emergency department and mental health community services which support service users with mental health and/or suicidal crisis. The seven included studies identified three support coordination interventions, two motivational interviewing interventions, an electronic record enhanced strategy and results from a phone follow-up study. This review demonstrates that support coordination, motivational interviewing, education, or an enhanced electronic record strategy can improve continuity of care, and in some cases, reduce the need for people to re-present to ED when they are experiencing mental health concerns or suicidal crisis. Results of this review reveal that a multipronged approach of communication pathways for continuity of care would enable more effective connections with mental health community supports and enable better outcomes for people requiring services.

The effectiveness of mental health disorder stigma-reducing interventions in the healthcare setting: An integrative review

Individuals with mental health disorders frequently seek medical treatment in health care settings other than a mental health facility. However, mental health disorder stigmatization is prevalent in the healthcare setting across the globe. Stigmatizing attitudes remain widespread among healthcare professionals who are responsible for delivering patient-centered, quality care. Stigma in the healthcare setting can undermine effective diagnosis, therapy, and optimum health outcomes. Addressing stigma is critical to delivering quality health care in both developed and developing countries. Therefore, it is important to deliver successful anti-stigma education, along with practical strategies, to reduce the stigma of mental health disorders among healthcare professionals. An integrative review was conducted to identify the effectiveness of various interventions used in 10 different countries globally to reduce the stigma of mental health disorders in the healthcare setting.

The clinical complexity of patients with acromegaly

OBJECTIVES

The main aim of the study was to investigate the factors related to the biopsychosocial complexity in the group of patients with acromegaly with different disease activity.

METHODS

A cross-sectional observational study was performed. First, a linguistic adaptation of the INTERMED - self-assessment questionnaire (IMSA) and after that the assessment of the biopsychosocial complexity among patients with acromegaly and the factors which relate to the complexity was made. The following tools were used to assess: biopsychosocial complexity: The INTERMED -self-assessment (IMSA); quality of life: The World Health Organization Quality of Life - BREF (WHOQoL) and Acromegaly Quality of Life questionnaire (AcroQol); mental state: The General Health Questionnaire - 28 (GHQ-28).

RESULTS

The final analysis included 71 patients. According to the principal component analysis the mental state (GHQ-28) and the quality of life (AcroQol) are the most important factors related to the clinical complexity among patients with acromegaly. In the model created by a stepwise regression analysis for the total IMSA score higher growth hormone (GH) concentration, longer illness duration, and better general quality of life were included as the protective factors of the clinical complexity. By contrast, a high score in the severe depression subscale of GHQ-28 was a factor of higher clinical complexity.

CONCLUSION

The mental state and quality of life are the most important determinants of the clinical complexity in the group of patients with acromegaly whereas the biochemical normalization is of lesser importance.

Interventions to change clinicians' behavior related to suicide-prevention care in the emergency department: a scoping review

OBJECTIVE

The objective of this scoping review was to explore, characterize, and map the literature on interventions and intervention components implemented to change emergency department clinicians' behavior related to suicide prevention using the Behaviour Change Wheel as a guiding theoretical framework.

INTRODUCTION

An emergency department is a critical place for suicide prevention, yet patients are often discharged without proper suicide risk assessments and/or referrals. In response, we must support emergency department clinicians' behavior change to follow evidence-based suicide prevention strategies. However, reviews to date have yet to systematically and theoretically examine interventions' functional characteristics and how they can influence emergency department clinicians' behaviors related to suicide-prevention care.

INCLUSION CRITERIA

This review considered interventions that targeted emergency department clinicians' behavior change related to suicide prevention. Behavior change referred to observable practice changes as well as proxy measures of behavior change, including changes in knowledge and attitude.

METHODS

This review followed JBI methodology for scoping reviews. Searches included PubMed, PsycINFO, CINAHL, Embase, and gray literature, including targeted Google searches for relevant organizations/websites, ProQuest Dissertations and Theses Global, and Scopus conference papers (using a specific filter). This review did not apply any date limits, but our search was limited to the English language. Data extraction was undertaken using a charting table developed specifically for the review objective. Narrative descriptions of interventions were coded using the Behavior Change Wheel's intervention functions. Reported outcome measures were categorized. Findings are tabulated and synthesized narratively.

RESULTS

Forty-one studies were included from the database searches, representing a mixture of experimental (n = 2), quasi-experimental (n = 24), non-experimental (n = 12), qualitative (n = 1), and mixed methods (n = 2) approaches. An additional 29 citations were included from gray literature searches. One was a pilot mixed methods study, and the rest were interventions. In summary, this review included a total of 70 citations, describing 66 different interventions. Identified interventions comprised a wide range of Behaviour Change Wheel intervention functions to change clinicians' behavior: education (n = 48), training (n = 40), enablement (n = 36), persuasion (n = 21), environmental restructuring (n = 18), modeling (n = 7), and incentivisation (n = 2). Based on the Behaviour Change Wheel analysis, many interventions targeted more than one determinant of behavior change, often employing education and training to improve clinicians' knowledge and skills simultaneously. Among the 42 studies that reported outcome measures, effectiveness was measured at clinician (n = 38), patient (n = 4), and/or organization levels (n = 6). Few studies reported implementation outcomes, such as measures of reach (n = 4), adoption (n = 5), or fidelity (n = 1). There were no evaluation data reported on the interventions identified through Google searches.

CONCLUSIONS

Interventions included in this review were diverse and leveraged a range of mechanisms to change emergency department clinicians' behavior. However, most interventions relied solely on education and/or training to improve clinicians' knowledge and/or skills. Future research should consider diverse intervention functions to target both individual- and/or organization-level barriers for a given context. Secondly, the ultimate goal for changing emergency department clinicians' behavior is to improve patient health outcomes related to suicide-related thoughts and behaviors, but current research has most commonly evaluated clinicians' behavior in isolation of patient outcomes. Future studies should consider reporting patient-level outcomes alongside clinician-level outcomes.

Interventions to change clinicians' behavior in relation to suicide prevention care in the emergency department: a scoping review protocol

OBJECTIVE

This review aims to explore, characterize, and map the literature on interventions implemented to change emergency department clinicians' behavior related to suicide prevention using the Behavior Change Wheel as a guiding theoretical framework.

INTRODUCTION

An emergency department is a critical place for suicide prevention, yet many patients who present with suicide-related thoughts and behaviors are discharged without proper assessment or appropriate treatment. Supporting clinicians (who provide direct clinical care, including nurses, physicians, and allied health professionals) to make the desired behavior change following evidence-based suicide prevention care is an essential step toward improving patient outcomes. However, reviews to date have yet to take a theoretical approach to investigate interventions implemented to change clinicians' behavior.

INCLUSION CRITERIA

This review will consider literature that includes interventions that target emergency department clinicians' behavior related to suicide prevention. Behavior change refers to observable practice changes as well as proxy measures of behavior change, including knowledge and attitudes. There are many ways in which an intervention can change clinicians' behavior (eg, education, altering service delivery). This review will include a wide range of interventions that target behavior change regardless of the type, but will exclude interventions that exclusively target patients.

METHODS

Multiple databases will be searched: PubMed, PsycINFO, CINAHL, and Embase. We will also include gray literature, including Google search, ProQuest Dissertations and Theses Global, and Scopus conference papers. Full texts of included studies will be reviewed, critically appraised, and extracted. Extracted data will be coded to identify intervention functions using the Behavior Change Wheel. Findings will be summarized in tables accompanied by narrative reports.

Association of Follow-Up After an Emergency Department Visit for Mental Illness with Utilization Based Outcomes

Follow-up within 30 days of an emergency department (ED) visit for mental illness is a new and widely-used quality measure. However, no empirical evidence validates associations between follow-up and subsequent utilization based outcomes. Using Massachusetts all payer claims data, we identified insured individuals with an ED visit for mental illness. Multivariate regression analysis estimated associations between follow-up within 30 days after an ED visit for mental illness with costs, hospitalizations, and additional ED visits in 180 days following the index visit. 63,814 index ED visits were included (56.5% female, mean [SD] age 38.0 [12.1] years, 48% Medicaid covered). 31% of index ED principal diagnoses were for major depressive disorder, 3% schizophrenia, 5% bipolar disorder, 34% anxiety disorder, 0.6% post-traumatic stress disorder, 8% other psychoses, and 19% other mental illness diagnoses. Only 33% of patients had a follow-up visit for mental illness within 30 days. Adjusted regression analyses show timely follow-up is associated with increased costs in the 180 days after (average marginal effect = $1622; 95% confidence interval [CI] 1459, 1786), an increased probability of inpatient hospitalization (2.7 percentage points; 95% CI 0.021, 0.032), and a small reduction in the probability of at least one additional ED visit (- 1.7 percentage points; 95% CI - 0.026 to 0.009). Overall follow-up rates are low; follow-up within 30 days of an ED visit for mental illness is associated with increased costs and increased probability of hospitalization in the follow-up period. It is not known whether increased rates of utilization improve patient outcomes, potentially by receiving appropriate more intensive care.

Forty years of emergency medicine research: Uncovering research themes and trends through topic modeling

STUDY OBJECTIVE

Topic identification can facilitate knowledge curation, discover thematic relationships, trends, and predict future direction. We aimed to determine through an unsupervised, machine learning approach to topic modeling the most common research themes in emergency medicine over the last 40 years and summarize their trends and characteristics.

METHODS

We retrieved the complete reference entries including article abstracts from Ovid for all original research articles from 1980 to 2019 within emergency medicine for six widely-cited journals. Abstracts were processed through a natural language pipeline and analyzed by a latent Dirichlet allocation topic modeling algorithm for unsupervised topic discovery. Topics were further examined through trend analysis, word associations, co-occurrence metrics, and two-dimensional embeddings.

RESULTS

We retrieved 47,158 articles during the defined time period that were filtered to 20,528 articles for further analysis. Forty topics covering methodologic and clinical areas were discovered. These topics separated into distinct clusters when embedded in two-dimensional space and exhibited consistent patterns of interaction. We observed the greatest increase in popularity in research themes involving risk factors (0.4% to 5.2%), health utilization (1.2% to 5.0%), and ultrasound (0.7% to 3.3%), and a relative decline in research involving basic science (8.9% to 1.1%), cardiac arrest (6.5% to 2.2%), and vitals (6.3% to 1.3%) over the past 40 years. Our data show only very modest growth in mental health and substance abuse research (1.0% to 1.6%), despite ongoing crises.

CONCLUSIONS

Topic modeling via unsupervised machine learning applied to emergency medicine abstracts discovered coherent topics, trends, and patterns of interaction.