Behavioural Emergencies in the USA – Lessons for the IFEM Community

Since its birth the specialty of emergency medicine has not focussed as much  attention to developing expertise in behavioural emergencies when compared with developing expertise in trauma and critical care. Unfortunately this has resulted in inadequate behavioural emergency training in residency programs in the USA[1]. 

While our residents are extraordinarily well-trained in trauma, cardiac emergencies, etc., any hint of a behavioural disorder in academic medical centers often prompts a “call psych” consultation. While waiting for the consultation the emergency medicine resident moves on to other patients and likely never learns how to manage the behavioural disorder. This system may work well in a tertiary care academic medical center, but breaks down when our emergency physicians end up at their likely employment in community hospitals where there usually is no “psych” to call.

The effects of this inadequate behavioural emergency training are seen in prolonged patient suffering, emergency department (ED) patient recidivism, prolonged patient stays in EDs exacerbating overcrowding, patient dissatisfaction and increased health care costs[2],[3],[4],[5]. As an anecdotal example, in my own experience as a faculty member in 3 different residencies, I found that the emergency medicine residents could not diagnose depression, a disease present in one in 5 of our patients[6],[7].

The care of other behavioural disorders besides depression suffers similarly in our emergency departments. Suicidality, an increasing problem worldwide, is under researched and lacks a consensus on how to assess risk. Anxiety disorders are often over treated with potentially addictive benzodiazepines. Opiate overuse in the past has contributed to widespread dependency, which now optimally should have treatment initiated in the ED rather than referral[8].  Patients with psychoses often sit for days waiting for a psychiatric bed to open up, while tying up an ED bed and staff.

IFEM announces speaker bureau for behavioural emergency medicine

Based on developed country ED usage extrapolated worldwide, there could be 250 million ED visits annually worldwide involving behavioural disorders in the near future[9]. We can and should do a better job of taking care of these patients. Fortunately IFEM, honoring its mission “to advance the growth of high quality emergency medical care through education…” has now established a speaker bureau that addresses behavioural emergencies. Available speakers and topics can be seen here.

If you would like to schedule a speaker for your residency program or for a conference please send a request.

David Hoyer, MD FAAEM
Chair, IFEM Behavioural Emergencies SIG

[1] Bode A, Jackson JS. The Current Emergency medicine curriculum: Missing psychiatry. Am J of Emerg Med. 2017; 35(11):1771-1772.

[2] Lora A, et al. Impact of depressive illness on emergency department recidivism: a new approach to the “frequent flyer”. Ann Emerg Med. 2004; 44(4):S23.

[3] Brickman K, et al. ED Patients with Prolonged Complaints and Repeat ED Visits Have an Increased Risk of Depression. West J Emerg Med. 2016 Sep.; 17(5): 613-616.

[4] Pailler ME, et al. Patients’ and caregivers beliefs about depression screening and referral in the emergency department. Pediatr Emerg Care 2009; 25: 721-7.

[5] Emanuel EJ. How Can the United Spend Its Health Care Dollars Better? JAMA. 2016; 316(24): 2604-2606.

[6] Abar B, et al. Access to Care and Depression among Emergency Department Patients. J Emerg Med. 2017; 53(1):30-37.

[7] Hoyer D, David E. Screening for Depression in Emergency Department Patients. J Emerg Med. 2012; 43(5):786-789.

[8] Sharfstein JM, Olsen Y. Lessons Learned From the Opioid Epidemic. JAMA. 2019; 322(9): 809-810.

[9] Owens PL, Mutter R, Stocks C. Mental Health and Substance Abuse-Related Emergency Department Visits Among Adults, 2007. HCUP Statistical Brief #92. July 2010. U.S. Agency for Healthcare Research and Quality, Rockville, MD. //www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf.