‘In case of crisis, go to A+E’

A+E can be an intensely frustrating place for mental health patients in crisis. Having recently finished another set of night shifts in the department, I thought it might be a good time to discuss why visits there seem to be so unsatisfying.

When I asked people for their experiences on social media, some did have very positive memories – but many others couldn’t have been less pleased with the treatment they received. Their responses were very useful in the writing of this blog and I’ve included some of their illuminating tweets throughout.

It seems that a lot of the time, these bad experiences were generated by a fundamental mismatch between what A+Es are designed to provide and what patients in mental health crisis actually need.

I’ve worked in A+E as a general medical doctor. The modern vision of an emergency department, especially following the implementation of the 4 hour breach target, is of a fast-paced and well-oiled machine designed to treat people quickly and move them on. The most urgent of procedures are carried out in the department (setting broken bones, resuscitation, stitching up cuts) but the onus is very much on getting the patients out.

Now, there are several ways in which A+E can be very useful to mental health patients using this style of working:

Ruling out a physical cause for your symptoms. Is this ‘psychosis’ actually an encephalitis, a thyroiditis or a brain tumour? Especially for patients presenting for the first time, performing a thorough batch of tests is essential. In my experience we hugely under-investigate psychiatric symptoms and probably miss quite a lot of treatable disease.

Providing a brief place of safety. Though many patients should undoubtedly go to 136 suites, there are certainly also a subgroup for whom A+E is appropriate. Acutely,  grossly intoxicated people who express a fleeting wish to harm themselves, for example, can be physically monitored and sleep off the risky thoughts.

Treatment for self harm and overdose. Having easy access to efficient medical help for these problems is a vital part of mental health care.

Getting an urgent prescription. It’s hardly ideal, but if you desperately need more of your tablets in the middle of the night, A+E is the only place to go.

Being the gateway to an emergency admission. Community and home treatment teams, in a perfect world, should be spotting and dealing with potential admissions during the day, but for the genuinely unpredictable emergencies, A+E can get you into psychiatric hospital – if there’s a bed.

But these positives struggle to cancel out the fact that the atmosphere and structure of A+E departments are directly at odds with perhaps the most important thing mental health patients actually visit the department for:

Emotional support during a crisis.

A+E departments are necessarily busy, noisy and impersonal. Because they’re used to caring for people on the edge of death and disaster all day, they’re built to ensure the emergency medical care is given efficiently – at the cost of ‘optional’ extras like complete privacy and tranquillity. Patients frequently overhear their names and conditions discussed in cold medical terms just outside their cubicle, detracting further from any sense of warmth.

The medical and nursing staff, used to taking bullet-point histories to exclude life-threatening disease and working long, exhausting shifts, don’t find it easy to suddenly switch into calm, reflective, empathic mode when someone comes in with self harm or another mental health problem. In fact sometimes their tiredness, mixed with a lack of mental health training, can even boil over into blaming the person for coming in.

The environment isn’t easy for mental health professionals either. As much as we want to help patients who turn up in the depths of despair in the middle of the night, it’s difficult to give them what they need. We often don’t know their history very well, it’s hard to form a rapport with someone you’ve just met, and we have a long list of other patients who need to be seen urgently too. That’s even if there’s a liaison psychiatry service – many hospitals still don’t even have one, meaning patients have to sit around in the department to see the team they need.

The opposite can happen too. The four hour target pressures departments to get people out quickly, when what patients in mental health crisis need is the exact opposite – somewhere to feel relaxed without any threat of rejection.

All in all, the lack of services on offer in A+E can lead to a complete disillusionment with the prospect of going there. So many patients tell me that despite the fact that patients are often told to go there, they are then simply told to ‘go home’, ‘take these tablets’ or ‘see their care team in the morning’. It can feel dismissive – but what else can A+Es offer? The things they’re good at – heroic lifesaving procedures, CPR, broken bones – isn’t any use to them with these problems.

It doesn’t help that often we put ‘in case of crisis, go to A+E’ on crisis plans. We need more appropriate places for people in mental health crisis to go. Drop in centres and crisis houses are far more suitable environments, but are just the type of services that get cut when the going gets tough – which it has. We need to prove that they’re good at making people feel better, deal well with crises and are therefore worth recommissioning. Going to a place where people are highly experienced in mental health and know you well, instead to A+E to see a random, bleary-eyed doctor, perhaps with little mental health training at four in the morning, shouldn’t be difficult to sell as a more therapeutic option.

Furthermore, to really get to the heart of this problem, we need to think systemically. Better staffed and funded community teams, social services and psychological therapy services could prevent crises before they even happen. By the time the patient gets to A+E, the horse has already bolted.

The Crisis Care Concordat highlights many of these problems, but I won’t be the first to reserve judgement until the money to fund the improvement appears and change genuinely starts to happen. Until then, unfortunately, for many people it’s A+E or nowhere.


About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

5 Responses to ‘In case of crisis, go to A+E’

  1. I have never been back to A&E in a crisis after I was made to feel very unwelcome there after my GP sent me there.

    For some reason, professionals think I’m being difficult when I try to explain that I wouldn’t go to A&E in a crisis if they paid me.

    The only time it ever got me anywhere, I spent the entire weekend in a 3 bedded unit designed for a stay of no longer than 12 hours, with nothing to do and no facilities – not even a shower, just a loo. I lied through my teeth just to get out of there in the end.

  2. self harmer says:

    I’ve felt I’ve wasted time for needing stitches for self harm many times. It’s standard for me now.

    I can’t sit still for the hours I have to wait. I have to go outside frequently to get away from the others within (social phobia). I’ve even switched off while waiting, this is the really scary bit. Much worse than the thought I’ll be missed when they call me. I have no control over anything when I switch off so am vulnerable.

    I don’t want to push any queues but need to wait somewhere quiet where I have some space to wander and be safe.

  3. elvis jones says:

    It would be a positive experience for me if some abusers did start to self harm. Personally, if I behaved like them no amount of scrubbing would ever get my hands clean
    It really annoys me that the victims of abuse end up blaming themselves, whilst the perpetrators behave like weasels. If one of those known abusers turned up at A and E I would advise them to scrub a bit harder or use petrol.

  4. elvis jones says:

    Many, many years ago I had an outpatient appointment with two doctors who new I was superficially cutting myself with a razor. They didn’t think much of this a joked among themselves that there would be blood running onto the carpet.
    This really upset me, being made fun of, and whilst drunk, I opened up the skin over my radial arteries. I went to AE and got sewn up.
    I’m not saying the doctors were unprofessional- if they want to stir up powerful feelings they can – assuming they actually know what they are and could handle them themselves . On this latter point I have some doubt. I think it could be quite dangerous for them really. I assume that the doctors felt at the top of their game, but I am no so sure they are as skilled as they believe. Normally when people behave in this laddish way in this circumstance then they are insecure. Casualty isn’t real life, it’s very artificial. If people were stabbed to death, spat on and then burnt with petrol, then you are getting closer to those I talk with.

  5. Somebody says:

    It’s never nice to have a nurse at the foot of your bed refer to you as the sectioned one, saying that there were others who were far nicer, making the time to talk to me despite the hustle and bustle of A&E. Saying that, I wonder whether it would have been different had I not a physical issue to treat as a result of my mental distress.

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