Is Mental Health a Problem in the ED?
Acute (and chronic) mental health issues in the ED, to me, represent one of the trickiest and perhaps most poorly dealt with presentations in Emergency Medicine. I am not claiming to have experience of all the EDs in the world, and I appreciate I am relatively junior in my career, but it is something that just doesn’t sit well with me.
Mental Health is not a sexy topic like trauma or toxicology; there aren’t any awesome procedures and there is little innovation. I think those of us who work in EM most enjoy making decisions under pressure and seeing the care we deliver make an immediate difference. Mental health doesn’t tick those boxes for us because it requires a lot of time to make a difference and often we achieve very little with these patients in the ED. I am guilty of sometimes being short-tempered and dismissive of some of these patients and I have seen the same in my colleagues from time to time. Sometimes we are downright rude.
We may lose sight of why a patient with a personality disorder or a patient who has resorted to self-harm has found themselves in that situation. We forget that some people have had an awful start to life and battled numerous social problems. There is a temptation to see them as a recurrent attender who is a nuisance and that goes against the ethos of the care we deliver in the NHS.
How Big is the Problem?
Mental health is a big issue and we really need to tackle it.
The Mental Health Foundation presents some astounding statistics on its website:
- A quarter of the population will experience a mental health problem in the course of a year.
- Depression affects 1 in 5 older people.
- Britain has one of the highest self harm rates in Europe (400 per 100,000).
To me these figures are pretty staggering. The Royal College of Emergency Medicine is aware of these issues. The college has developed a toolkit for providing care to patients presenting with mental health problems and has outlined the following standards. These are really great pointers to helping to deliver the right care to this group of patients in the ED.
- Patients who have self-harmed should have a risk assessment in the ED
- Previous mental health issues should be documented in the patient’s clinical record
- A Mental State Examination (MSE) should be recorded in the patient’s clinical record
- The provisional diagnosis should be documented in the patient’s clinical record
- Details of any referral or follow-up arrangements should be documented in the patient’s clinical record
- From the time of referral, a member of the mental health team will see the patient within 1 hour
- An appropriate facility is available for the assessment of mental health patients in the ED
It’s not just in adults that we need to think about mental health. The stats below are from an organisation called YoungMinds and shows the prevalence of mental health issues in children. We can make a huge impact if we bear these figures in mind and act appropriately and sensitively in a timely manner.
- 1 in 10 children and young people aged 5 – 16 years suffer from a diagnosable mental health disorder – that is around three children in every class.
- Between 1 in every 12 and 1 in 15 children and young people deliberately self-harm.
- There has been a big increase in the number of young people being admitted to hospital because of self harm. Over the last ten years this figure has increased by 68%.
- More than half of all adults with mental health problems were diagnosed in childhood. Less than half were treated appropriately at the time.
- Nearly 80,000 children and young people suffer from severe depression; more than 8,000 of those children are aged under 10 years.
- 72% of children in care have behavioural or emotional problems – these are some of the most vulnerable people in our society.
- 95% of imprisoned young offenders have a mental health disorder. Many of them are struggling with more than one disorder.
- The number of young people aged 15-16 with depression nearly doubled between the 1980s and the 2000s.
- The proportion of young people aged 15-16 with a conduct disorder more than doubled between 1974 and 1999.
Can we do better?
At the heart of this is compassion. We need to remember that often the most challenging and disruptive of patients are the ones who need our patience and kindness the most. We see these patients maybe once a week, maybe once a month, or maybe every day. We see them for an hour or two before they get discharged. We may offer the only opportunity for these patients to be met with respect and dignity. I want to avoid sweeping generalisations and making inaccurate assumptions, it is simply a thought. Increasingly I have tried to be mindful of this when seeing such patients. Patients may be scared, attending the ED as a last resort and we should be sensitive to this.
I would encourage everyone working in the ED to familiarise themselves with the guidance provided by NICE. The guidelines available cover self-harm, depression, depression in children, anxiety, personality disorders and alcohol use.
MoodGym is an awesome resource developed by National Institute for Mental Health Research in Australia. It is a fantastic online cognitive behavioural therapy (CBT) tool. For those unfamiliar with cognitive behavioural therapy it (very basically) explores the relationship between our thoughts, feelings and behaviour. If we change the way we think, we can change the way we feel and behave. CBT has been demonstrated to be effective in many personality disorders, schizophrenia, anxiety and depression. We may not be able to help patients in the ED but we can put them on a path to helping themselves.
Treating patients with mental health problems in the ED is challenging. Mental health resources are overstretched in the NHS. There are no easy solutions. Some patients will never be able access the resources they need. We can offer a kind ear and a friendly face and we must try to be patient. However lacking the onward services our patients need, we must continue to treat patients with dignity and respect.
Most of all, be kind.
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