Why Ontarians in mental health crisis turn to hospital emergency rooms

By Iman Sheikh - Published on May 5, 2016
a young man with head in hands in a hospital waiting room
The hospital ER isn't an ideal place for people in psychiatric distress, doctors say. But where else can they go?

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Where do young Ontarians with depression and anxiety go for help? Apparently, to hospital emergency rooms. Earlier this year, a study published in the Canadian Journal of Psychiatry found emergency room visits by Ontarians age 10 to 24 with mental illness increased by 33 per cent between 2006 and 2011.

While such an increase may indicate that more people are seeking help for mental health issues, experts insist that the emergency room is often not the place to go.  

“The most common reasons people come to the ER has nothing to do with diagnosis. It has to do with an access problem,” says Dr. Paul Kurdyak, director of health systems research at the Centre for Addiction and Mental Health in Toronto.

Although many hospitals offer emergency psychiatric services, they are often located inside larger emergency departments and are accessible only by referral from the hospital’s emergency department. For example, psychiatric care is available around the clock at St. Michael’s Emergency Department in Toronto, but upon arrival an individual seeking help must be seen by the emergency nurses and doctors first.

CAMH has one of the province’s only 24-hour emergency walk-in centres dedicated to psychiatric care, and the Toronto facility announced in late 2014 that it had improved and doubled the space available for 24/7 care for patients in crisis due to rising demand from patients — and law enforcement.

“Increasingly, we’re seeing a lot more police dropoff traffic too,” says Kurdyak. “Police picking people up off the street will bring them to us. We get police in and out in 20 minutes, so we’ve become a preferred place for them.”

During the period studied, the number of hospital admissions for mental health-related issues rose by 53 per cent. But visits to community-based doctors increased by only about 15 per cent during the same time. Family physicians were seen most often, followed by psychiatrists and pediatricians.

“A lot of the psychiatric emergencies we’re seeing are preventable through better access,” Kurdyak says.

The psychiatrist access problem is complicated and many factors contribute to the disconnection between patients and treatments. Among these are a fear of social stigma, an inability to pay out-of-pocket for services such as psychiatrist fees and not knowing where to find help. One-third of emergency department visits for a mental illness or addiction are by people who have never been assessed and treated for these issues by a physician previously, according to a 2015 report by Health Quality Ontario.

“Stigma, though improving dramatically in society, still exists,” says Dr. Steven Harrison, CEO of the Canadian Mental Health Association’s Middlesex branch. “One of the hardest nuts to crack is having people in the community, your family, your friends, your social circle, truly understand that because you’re going through a mental health crisis it doesn’t mean that you’re less of a person and it doesn’t mean that you’re sick.”

Another serious hurdle to finding care is the supply and demand problem of psychiatrists in Ontario. A 2014 study published in Open Medicine found that many of the province’s psychiatrists were concentrated in the two largest cities, Toronto and Ottawa. But Kurdyak, co-author of the study, said he learned that finding a psychiatrist who accepted new patients was not any easier in Toronto than in regions with far fewer psychiatrists.

“There’s a supply-demand mismatch even though there are way, way more psychiatrists in Toronto and Ottawa,” he says.

What the study found was that as the supply of psychiatrists increased, the total number of patients each psychiatrist saw decreased. Therefore, increasing the supply of psychiatrists did not necessarily improve access for patients who need psychiatric services.

The province needs more round-the-clock options. London’s new Mental Health & Addictions Crisis Centre has had around 1,000 visitors between its opening this past January and the end of March. Operated by CMHA Middlesex, the centre treats walk-in patients over 16 years of age. Harrison says opening it made sense, given that many patients were heading straight to London Health Science Centre’s emergency department because they were in crisis, but did not need a medical intervention. They also often got pushed to the background in the process.

“When faced in an ER with an individual who has a laceration or has been in a car accident or something like that and someone who is in a state of mental health crisis, you generally take the person who’s bleeding on the floor over the person who seems to look OK,” Harrison says. “But there may be other issues going on inside that you can’t necessarily see.”

The noise level and frenetic activity of a busy emergency department are also not ideal for someone already in mental distress, according to Kurdyak.

The problem of follow-up after a patient is discharged from the ER also persists. “We do try to do some follow-up but it’s very difficult,” Harrison says. “There’s a large homeless population in town, and also for a lot of people this conversation about having a mental health struggle might not be welcomed within the family. They don’t necessarily want you calling home saying ‘How are you doing?’ after you visit the crisis centre.”

The rise in traffic through crisis centre doors, while encouraging, is also bittersweet. “About 70 per cent of people coming through the door are first-time attendees for mental health supports,” Harrison says. “These are people who have never traditionally in the past ever thought that they needed it or knew where to go. The scary statistic is that 60 per cent of people who come in the door are under the age of 35.”

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