Research describes challenges of ER care for mental health and substance use disorder patients

Across the country, one in eight visits to the emergency department (ED) involves psychiatric or substance use concerns – and the frequency of such visits continues to rise. 

It’s no news flash among social and public health scientists that “the health care system is terribly broken – and for patients who suffer from mental illness or substance use disorders, it’s particularly broken,” says Linda Isbell, the Feldman-Vorwerk Family Professor in Social Psychology at the University of Massachusetts Amherst.

A first step toward addressing these issues is understanding and describing them. In research published Thursday, Jan. 19 in the Annals of Emergency Medicine, Isbell and her colleagues have for the first time developed a comprehensive, data-driven model of the challenges and care dynamics associated with providing ER care to patients with mental health and substance use disorders.

“It’s probably the largest qualitative study on this issue that has been done with physicians and nurses,” Isbell says.

The current research, which resulted from interviews with 86 ER physicians and nurses working in eight hospitals in the Northeast U.S., is part of a larger study published in 2020 in BMJ Quality and Safety that looked at the emotions experienced by health care providers in the ER. 

Isbell and her team, including Edwin Boudreaux, professor of emergency medicine, psychiatry and quantitative health sciences at UMass Chan Medical School, describe interpersonal, logistical and systems barriers that make it very difficult, and sometimes impossible, to properly diagnose and treat ER patients with substance use disorders and psychiatric conditions. Based on lengthy in-depth interviews, the researchers developed a grounded model of the cycle of care that can adversely affect both the patient and health care provider.  

The model shows that emotional, diagnostic and logistical challenges that ER physicians and nurses face when caring for patients with mental health or substance use disorders can “interact with pre-existing attitudes and biases, which results in negative care experiences with these patients,” the paper states.

Isbell and team find that this cycle can affect decisions about medical care for a challenging patient population that shows up for care that the ER was not designed to provide.

The researchers conclude that “broad public and institutional changes” must occur to improve emergency care for this patient population. “…As our physicians and nurses described, interventions and policy changes that address the unique challenges are urgently needed.”

“We don’t want to blame providers,” Isbell says. “There is so much stress in the emergency department and these data were collected prior to COVID, and COVID stresses have just magnified everything.”

The paper states, “Often unprompted, physicians and nurses reported fatigue, helplessness, frustration, and inefficacy when caring for these patients.” 

The patients are difficult to diagnose, and they may have altered mental states due to alcohol, other substances or psychosis. Few opportunities exist for inpatient placement, Isbell notes, when it’s needed. The paper describes that these and many other factors can have substantial consequences for patients. For example, some providers may do less thorough examinations of these patients, attributing physical health complaints to mental illness or substance use.

“You can do medical screens in a halfhearted way, or you could do them thoroughly, and if you believe that the person has a mental health issue, you may actually not do it quite as carefully,” Isbell says.  “For example, the chance of dizziness or some other physical health complaint not being taken seriously into consideration is higher for the person with bipolar disorder or another mental health condition than for a person who doesn’t have a psychiatric diagnosis.”  

She notes that this may not always be a conscious decision by providers, especially considering the resource-depleted and cognitively demanding conditions that characterize most emergency departments; however, she notes that stigma and biases are common in medicine, as they are everywhere else.

Isbell says that under the current conditions, it’s not possible to provide the most appropriate and necessary care in the ER to this patient population.

The paper summarizes, “Large-scale changes in public policy, legislation, investments, and rigorous evaluations are essential to expand the mental health care systems and provide alternative sources of care (e.g., call centers, crisis care facilities), fund evidence-based services, increase community resources, and improve transitions of care from EDs to community services.”