Last year, the Journal of Paramedic Practice posted a news article via social media on screening for mental health and the impact this has on length of stay in the emergency department in order to stimulate discussion. The article referred controversially to mental health as ‘behavioural’ health. There are dangerous implications of this terminology for patients with mental health conditions, as well as for health professionals, and the provision of care in general.
Primary mental health presentations make up at least 10% of the prehospital workload (Duncan et al. 2019)—and this does not take into account secondary presentations. Globally, there have been substantial cuts to already-stretched mental health services, meaning that many patients feel they have no other choice than to access emergency care (Wolf et al, 2015; Roggenkamp et al, 2018). Despite national guidelines outlining the importance of all clinicians involved in mental healthcare having sufficient education and support (National Institute for Health and Care Excellence (NICE) 2004; World Health Organization (WHO) 2013), prehospital clinicians often have poor confidence and limited education regarding care for this patient group (Rees et al, 2018; Emond et al, 2019). Alongside this, a lack of alternative care pathways to refer those in need to services in the community mean that a large number of these patients are taken to accident and emergency (A&E) departments as a place of safety (Rees et al, 2018).
It is recognised that A&E is often the wrong environment for someone having a mental health crisis, and that standards of care are often below those assigned to physical health issues (Mind, 2011; Duncan et al, 2019). The barriers to providing high-quality care are multifaceted; from diagnostic overshadowing, to poor understanding of the complex relationship between physical health and mental health, busy departments, stigma and compassion fatigue from repeated seemingly ‘minor’ or ‘inappropriate’ presentations (Crowley and Kirschner 2015; Ford-Jones and Chaufan 2017; Cromer-Hayes and Seaton, 2019). We all have a responsibility to break down these barriers and promote equality across healthcare.
The article
Screening behavioural health patients in ED reduces length of stay (Castellucci, 2020), hereby referred to as ‘the article’, discusses measures taken in a series of A&E departments within the United States (US), to explore some of the barriers to help these patients and namely reduce the time such patients spend within the department. While it discusses US healthcare, mental health issues are a significant global burden (WHO, 2012), with the barriers to accessing mental health care seemingly universal (Andrade et al, 2014).
Although the concept of reducing the time in department for any group of patients, particularly for whom it might be especially distressing, is a great concept, the content of the article raises concerns about attitudes towards this group of patients in healthcare, particularly emergency medicine. The use of ‘behavioural health’ to describe mental health, sweeping statements around presentations and required outcomes, and suggestions around length of stay being a primary outcome for prescribing decisions are seriously concerning. However, whilst it makes several frankly abhorrent points, can we all use it as a tool to learn, and avoid making those mistakes ourselves?
‘Behavioural’ versus ‘mental’ health
The verb ‘behave’ means ‘to act in a particular way’ or ‘act in a way that is considered correct’ (Cambridge University Press, 2020), with the definition of ‘behaviour’ within psychology being ‘an organism's activities in response to external or internal stimuli…’ (American Psychological Association, 2020). These definitions strongly imply that an individual has at least partial control over their behaviour. The definition of ‘behavioural health’ has generally been defined as a combination of mental health, substance use, personal habits, and environmental influences—but there has been common misuse of it as an interchangeable term for ‘mental health’ (Crowley and Kirschner 2015; Alvarado Parkway Institute (API) 2018; United States House of Representatives DATE U/K), with negative perceptions of the term accepted (Sandler, 2009; Tracey, 2011). The Agency for Healthcare Research and Quality (Crowley and Kirschner, 2015) has created a lexicon to standardise understanding of the term ‘behavioural health’, and states that it is a ‘broad term used to encompass care for patients around mental health, and substance abuse conditions, health behaviour change, life stresses and crises, as well as stress-related physical symptoms’ (Davies et al, 2013).
It is clear that ‘behavioural health’ encompasses all aspects of health and human behaviour, and is not interchangeable with mental health. Doing so implies an element of choice or conscious decision-making, ignoring the fact that ‘behaviours’ seen in those with mental ill health, such as deliberate self-harm, suicidality or deranged thought patterns, are due to underlying illness, and are not solely due to conscious decision-making or environmental factors; it is simply not that straightforward. While patients presenting to A&E often do so with multifactorial problems, and therefore behaviour may play a part, the article (and the hospitals it discusses) use this overriding label to describe those with mental health presentations, such as those needing psychiatric medications, or expressing suicidal ideations, which is deplorable. These patients already struggle to access all areas of healthcare for a multitude of reasons, making it of paramount importance that we all use the lexicon appropriately, break these negative perceptions, and avoid inappropriate and inaccurate labelling.
Risk assessment in emergency care
The article describes measures to improve the patient experience within A&E, including a screening process to risk-stratify ‘behavioural health patients into low–medium or high-risk categories’ (Castellucci, 2020), a concept that is positive at first glance. It is widely accepted that all patients require a patient-centred approach as opposed to a one-size-fits-all assessment, and those with mental health problems are no different (Mind, 2011; National Institute for Health and Care Excellence (NICE), 2011). While the ‘series of questions to understand what brought them into the ED’ (Castellucci, 2020), is not clear, the sweeping statement that those coming in for medications are automatically low risk, and those with suicidality are high risk, shows a gross misunderstanding of the complexity of patients with mental illness presenting to A&E.
The article notes that those deemed ‘low risk’, based on the initial questions, such as those looking for a medication refill, are signposted to crisis health workers, which is in line with best practice to signpost people to more appropriate services at triage (Royal College of Emergency Medicine (RCEM), 2019). However, best practice guidelines require anyone presenting with a mental health-related problem to be triaged properly by an appropriately trained health professional for a true assessment of risk (Weber at al, 2017; RCEM, 2019); the article strongly implies this is not the case, seriously putting patients at risk. It is acknowledged that one of the difficulties in assessing risk in patients is that people often withhold information (Mérelle et al, 2018), so if patients are not being given appropriate and sufficient time to talk with someone trained to speak to them, a simple ‘I've run out of medication’, could well be a front for something else more sinister.
The suicidal patient—what's the risk?
The assumption that patients presenting with suicidal ideation are all high risk, and that they ‘usually require an admission to an inpatient psychiatric unit’ (Castellucci, 2020), is truly scary. It implies an assumption that all patients who express suicidality are at immediate risk of death, and that inpatient treatment is the only and safest option, neither of which are true.
Suicidal ideation is complex, and the assessment of such requires a comprehensive, holistic, clinical approach. Anyone who is thought to be at risk of suicide (whether or not they have expressed suicidality), needs to have this dynamic, non-judgemental, holistic clinical assessment, which then stratifies them into low, medium or high risk at that time, with points-based risk-stratification being actively discouraged as assessment tools to determine current or future risk of both self-harm and suicide (NICE 2004; Jacobs et al, 2010; NICE, 2011; Bolton et al, 2015; Weber et al, 2017). Worryingly, the article references actual practices within the group of hospitals, with the risk-stratification being based on the initial questions asked to ‘understand what brought them into the ED’ (Castellucci, 2020), rather than an actual mental health or suicide-specific risk assessment.
Place-of-care post assessment
Once a patient has been thoroughly assessed, the appropriate action plan—be that immediate or delayed further assessment by a specialist, pharmaceutical, non-pharmaceutical or combination therapy—and the location in which this should take place, is very patient- and situation-specific, and should be the least restrictive option (WHO, 2003; Jacobs et al, 2010; Department of Health and Social Care, 2015). A sweeping statement that all suicidal patients are likely to require inpatient care is either inaccurate, or an example of very poor and potentially dangerous practice.
Several factors affect the urgency, type and location of intervention (Jacobs et al, 2010), the details of which go beyond the remit of the present article, but even by focusing on patients deemed to be high-risk post assessment, it is not as simple as admitting them to a psychiatric unit. There is overwhelming evidence that admission to an inpatient unit actually increases risk of harm in patients with underlying mental health issues, and that many patients can not only be safely managed in the community setting, but will do much better in this scenario (Mind, 2011; Bolton et al, 2015). In addition to this, many patients with ongoing mental ill health risk are reluctant to seek help for fear of admission (Sweeney et al, 2015), so attitudes like this are simply adding to difficulties that vulnerable patients face in accessing care.
What to prescribe: length of stay is not the answer
Arguably, the key point of the article is around length of stay within the department, and the use of sedating medications is blamed as a fundamental obstacle for rapid assessment and discharge or referral. The details surrounding the improvements in this aspect of practice are limited but ‘educating physicians about the options’ (Castellucci, 2020) after recognising that doctors tend to be prescribers of habit, appears to be the focus. It is noted that ‘93% of physicians are prescribing newer antipsychotic medications’ that are less sedating post implementation of the education programme (Castellucci, 2020).
On first reading, it appears common sense to reduce side effects of medications for patients, with sedative impact of medication often cited by patients as a reason for poor compliance (DiBonaventura et al, 2012). Side effects, including altered cognition, and increasing suicidality risk, vary from person to person and, if overdose is a concern, medications with lower risk of excess must clearly be prioritised (Bolton et al. 2015; NICE 2020a; 2020b). It is also important to note that there is no ‘one size fits all’ with medications used in mental healthcare with regards to efficacy or need, with some patients benefitting from side effects such as sedation. Furthermore, while there is some evidence that second-generation medications have fewer negative side effects (NICE, 2020a; 2020b), the decision-making must be focused on patient-specific therapeutic need, and actions to prioritise admission duration are putting patient care at risk. The article does not give enough information around its prescribing decisions, but it does imply that they should prioritise the impact on admission times, and that less sedating medications should be prioritised solely for that attribute. Other aspects of the article have suggested other areas of poor practice, which does not support a positive stance on prescribing decisions.
What does it mean for paramedics?
It is important to understand the differing needs of the diverse range of patients who present to emergency care, for both urgent and non-urgent issues, and the additional challenges those with mental health issues pose, both for their own care, and the wider impact on the healthcare system. Prehospital care providers deal with both urgent and non-urgent presentations of mental illness, and despite limited education and opportunities for appropriate referral, it is essential that everyone understands their role in caring for this vulnerable group of patients, who often have complex needs.
The article discussed highlights efforts to implement improved care for this group of patients within ED in a group of hospitals in the US, by primarily focusing on how to reduce their length of admission within the department. The concepts of limiting time within the department, ensuring assessment and treatment are patient-focused and up-to-date are laudable; however, it has highlighted several ongoing barriers that these patients face when trying to access care. Inappropriate terminology and labelling, lack of true assessment, scaremongering regarding outcomes and prescription decisions based primarily on departmental need, amount frankly to poor practice, only adding to the already-numerous issues faced by this patient group.
Take-home lessons
However, as prehospital clinicians, we can learn from this. We can improve our own understanding of the importance of appropriate language, and the sensitive use of labels that might be damaging to the patient's perception of the clinician's attitude or themselves, as well as our own perceptions. While there are many limitations to the prehospital clinician's management of these patients, we should learn from the problems of sweeping assumptions, to ensure our own practice is tailored to the patient in front of us, and the situation they are in.
Finally, while prescribing is a relatively new concept in paramedic practice within the UK, it is of paramount importance that all those working in the field of prehospital and emergency care are aware of the importance of balancing therapeutic need and side effects, and the need to prioritise the most appropriate measures for optimal patient care and outcomes.