Emergency Psychiatry in the General Adult Population: Clinical and Training Approaches

Introduction

The emergency department (ED) continues to be a portal of entry for many of the most acutely ill patients we treat.^3–5 Despite an ever-expanding repertoire of psychotropic agents, and increasing numbers of graduate psychiatrists, many people with psychiatric illness present to EDs across the country in need of psychiatric care. There is recognition that our training programs need to prepare our future psychiatrists to safely and effectively assess, diagnose, and manage this particular patient population.

Since the publication of the Canadian Psychiatric Association's (CPA's) 2015 position paper on emergency psychiatry, ² the Royal College of Physicians and Surgeons of Canada (RCPSC) has elucidated more specific training requirements in this area. ⁶ Concurrently, models of care for the psychiatric patient in the ED have evolved, both systemically and therapeutically. More attention and recognition of equity, diversity, and inclusiveness in the emergency setting has emerged. This paper presents an emergency psychiatry update, with an emphasis on training and education.

Emergency Psychiatry Training: The Canadian Experience

In August 2021, the authors distributed an updated survey to all psychiatry residency programs in Canada. The survey was targeted to emergency psychiatry curriculum/rotation leads if applicable, or program directors if not. There were a total of 30 respondents, with 16 out of 17 postgraduate programs represented.

Similar to 2015, there was considerable variability across and within programs. As a result, the structure of the rotation, supervision provided and collaboration with other health-care providers differed greatly. Regarding emergency psychiatry clinical exposure, programs provided between 1 and 16 weeks of training, which is an increase compared with the 2015 survey results. Training sites varied; most programs offered a designated psychiatric emergency unit within a general hospital ED, and a minority trained in a specific psychiatric ED or a general hospital with no designated psychiatric unit. Notably, many programs trained at more than one site, which increased the amount of exposure to emergency psychiatry in varied settings.

Approximately 70 per cent of programs offer additional safety training to residents as part of their emergency psychiatry training, with the most common program amongst respondents being Nonviolent Crisis Intervention. With respect to safety features, most settings offer designated psychiatric interview spaces, personal panic alarms, and video surveillance. About half of the sites have security staff at all times in the department, with the other half having security available by request.

Slightly less than half of programs offered an urgent care or rapid access clinic through the emergency psychiatric service; this varied in programs with multiple training sites. Most programs indicated that residents are not involved in these clinics though a few participated as part of their emergency or ambulatory rotations.

Didactic lectures remained the most common teaching method across programs, with only a small minority (less than 10 per cent) involving simulation or standardized patients in training. The amount of curricular teaching also varied widely, between 1–5 and over 21+ hours, and many respondents were unsure of exactly how much curriculum time was dedicated. The most commonly covered topics were suicide risk assessment, management of agitation, violence risk assessment, and Mental Health Act legislation, in that order. Less common topics include racism, stigma, and supporting Indigenous populations in the ED.

On-call work remains a cornerstone of training in emergency psychiatry. Models of call vary across the country and even within programs, depending on the hospital site, with the majority of residents primarily taking “home” call or a blended model (i.e., in hospital until a certain time and then at home), and a large minority doing primarily in-hospital call. The most common call frequency was 1 in 7, though this tends to decrease as residents progress, with PGY5s and 6+ more likely to work a frequency of 1 in 9. The majority of residents participate in overnight call with a postcall day, and a minority of sites and programs only have evening call with no postcall day. In most settings, residents are supported by staff psychiatrists either at home or in hospital until a certain time, at which point they go home. A small minority, approximately 10 per cent, have staff psychiatrists in-house throughout the call period. While on-call, residents are primarily responsible for covering ED consultations (this was the case across all programs) and at some sites, residents may also cover the psychiatric inpatient units, consultation/liaison requests from other services, and calls from the community. Some sites have separate residents available for emergency coverage and unit coverage.

The majority of sites do not have graduated responsibilities for call as residents progress through their training, though there may be a “buddy call” system in which PGY1 residents are paired with senior residents prior to taking call independently. If more than one resident is on call at the same time, there may or may not be any differences in responsibilities, though efficiency was noted as a common priority regardless of the stage of training. In these situations, some sites have senior residents taking consults and triaging, though some sites have junior residents performing these tasks. Overall, there was no consensus or standard approach to graduated call responsibilities.

With respect to the transition to competency-based medical education (CBME), there was a high degree of variability within programs, both in terms of the changes that have occurred and the stage of implementation. More than half of the programs have a dedicated emergency psychiatry curriculum or rotation lead, though a substantial number of respondents (17 per cent) were unsure if this position existed. The most practical difference appears to be the introduction and use of entrustable professional activities (EPAs) as a unit of assessment as per the Royal College Competence by Design (CBD) program. Most programs are now using EPAs in some capacity, with 80 per cent making use of these during the core emergency rotations, but only 30 per cent using them for assessment in the on-call setting. The overall feedback for the transition to CBME appears mixed and it appears that these changes are mostly still in the early stages of implementation. There were comments indicating that the emergency setting can be very busy and it can be difficult to find time for direct observation and additional assessments. However, the high volume of clinical work available in this setting can also provide an excellent educational opportunity for meeting general psychiatry assessment requirements.

Emergency Psychiatry Systems and Settings

There is increasing recognition that the assessment of the psychiatric patient in crisis must take place in thoughtfully designed environments, with attention to the safety of patients, learners, and staff. The ideal location for emergency assessments would be in a designated space for patients with mental health concerns as noted at triage, either in a general hospital or psychiatric facility. ⁷

General hospital EDs have the advantage of medical support but the psychiatric hospital has the expertise of trained emergency staff who are specialists in the care of psychiatric patients. The patient will be seen by those trained to empathically and knowledgeably assess and treat psychiatric illness. Regardless of the setting, the emergency psychiatry team should be composed of psychiatrists, psychiatric nurses, clinicians (e.g., social workers and psychologists), and psychiatric assistants with access to security. ⁷

It is essential that the setting for the emergency assessment be equipped with full safety features, whether in the general or psychiatric hospital environment. Designated interview rooms, with features such as alarm buzzers, video monitoring, sight lines to nursing stations, nonbreakable glass, thoughtfully designed furniture (weighted or bolted), and nonbarricadeable doors, are recommended in designing a psychiatric ED. ⁸

In addition to the traditional model of hospital-based emergency assessments, there are numerous alternatives that should be considered. Many people with psychiatric illness cannot access family physicians or reliably follow up with appointments in the community. In smaller urban and rural hospitals, resource pressures have made it impossible to set up a dedicated psychiatric emergency service. Other options include community crisis teams, community crisis beds, and specialized mental health units within police forces to deal with emergency mental health situations.^9,10 Regardless, exposure to multiple types of settings within the residency training program will help prepare residents for practice in areas with varying access to resources.

Crisis services are an essential component of emergency psychiatry care. Timely follow-up after the emergency visit, within a week to 10 days, allows for a reassessment of high-risk patients and the opportunity to further link to hospital and community services. Embedding crisis or urgent care work within the emergency psychiatry rotation allows learners the opportunity to provide longitudinal support and reassessment after the acute ED presentation. Innovative models of crisis care have been developed to meet the increased need, where individuals can access assessment and treatment on a walk-in basis, with extended hours during evenings and weekends.

COVID-19 has allowed for the introduction of virtual care into psychiatric practice in a multitude of settings. Emergency assessments can be performed over authorized media platforms between hospitals and for crisis care once the patient has been discharged. Crisis follow-up can occur virtually if the patient has familiarity and access to the technology as well as privacy options. But for many of those presenting to EDs, this may not be possible and in-person appointments need to be maintained. ¹¹ Learners have been incorporated into crisis clinics and benefit from opportunities to assess and follow emergency patients over the course of their rotational blocks.

Common Emergency Presentations

Agitation/Violence and Risk to Others

Acute agitation is a common reason for referral to an emergency psychiatric service. In a US study, 50 per cent of psychiatric presentations to the ED involved agitation. ¹² Assessing the agitated patient can be an anxiety-provoking experience for psychiatry residents. Resident training programs must provide education to address both the assessment and the management of the agitated patient in the ED. Various etiologies including medical, substance, and psychiatric, can precipitate agitation. It is optimal that medical causes for agitation be addressed prior to or along with a psychiatric referral. This is not always achievable when the patient arrives in the ED in a state of agitation. At a minimum, the triage of the agitated patient should include vital signs, with oxygenation level and blood glucose level, when possible. ¹³

The psychiatrist or trainee working in the ED requires a safe environment prior to initiating the assessment of the agitated patient. Prior to interviewing the patient, the level of agitation should be determined to best prepare the interview approach. Safety and infection controls should be considered. Speaking to the referring physician and reviewing past charts can be helpful in determining the risk of potential violence. Visualizing the patient prior to engagement to observe the mental status is recommended. Working in a team is crucial, and the emergency psychiatrist or trainee must determine when additional staff will be required for support. Recognizing the state of agitation, from anxiety to verbal threats, to overt aggression, is essential, as the interview approach and intervention will need to be paired to match the type of agitation and de-escalation will follow accordingly.

The American Association of Emergency Psychiatry (AAEP) has published consensus guidelines on agitation that are not only effective and safety-minded but also patient-centred. ¹⁴ The CPA has also published a position statement suggesting the use of the least restrictive methods of restraint, only in emergency situations, to prevent immediate harm. ¹⁵ Previous guidelines have tended to focus on environmental systems and medication strategies^16,17 but, for the first time, a comprehensive document has been created addressing all aspects of intervention, from medical triage to assessment, verbal de-escalation and, ultimately, pharmacologic management.

Practitioners should aim to minimize the use of coercive approaches to care including the use of locked seclusion. If seclusion is required, ensuring regular observation of the patient is essential as per hospital least restraint policies. Minimal restraint is temporary and meant to protect the patient and others, and the means include both mechanical and chemical. Patient restraint is intrusive and can be experienced as traumatic, though may still be necessary in the presence of emergent safety concerns. There is a risk of physical and psychological harm and may be a last resort option to manage imminent risk of harm to self or others. Two broad classes of medications are most commonly used in managing the agitated patient—benzodiazepines (BZDs) and antipsychotics (APs). APs are divided into first- and second-generation (FGAs and SGAs, respectively) options. There are multiple routes available for delivery of these medications including oral, sublingual (SL), fast-dissolving, intramuscular (IM), and intravenous. The choice of medication or medication combination, as well as the route of delivery, will be influenced by diagnostic impression and the severity of the agitation, as well as availability and practicability. ¹⁸

Currently, there is no rationale to support the former practices of rapid neuroleptization, and possibly even rapid tranquilization, whereby large cumulative doses of medications are given in a short period of time to induce sedation. At this time, it is recommended to work towards a goal of calmness by administering the medication based on the knowledge of specific pharmacokinetics. Oversedation to the endpoint of sleep would preclude the ability to interview and assess. When at all possible, oral medications should be offered prior to IM injections. More agitated patients will require routes with accelerated onset, such as SL or IM. The most important determinant of medication choice is the working diagnosis. APs, with or without a BZD, are indicated as first-line management for patients with psychosis of psychiatric origin. Typically, the high-potency APs, both FGA and SGA (e.g., haloperidol and risperidone), will require a BZD for sedation. For agitation due to intoxication, BZDs will be the preferred agents. The BZD of choice in the ED is lorazepam, for its safety profile and multiple options of delivery. ¹⁸ With the delirious patient, BZDs should be avoided. The preference would be to use high-potency APs to minimize possible anticholinergic side effects, and, of course, treating the underlying cause would be essential. Important distinctions between the American guidelines and Canadian approaches include the availability of loxapine in Canada, a mid-potency FGA that is a more cost-effective option than the SGAs and is available as an IM injection. This medication is commonly used at an initial dose of 25 mg, oral or IM, but can range from 12.5 to 50 mg depending on patient factors. For the most severely agitated patients, combined haloperidol and lorazepam IM remains an extremely effective option. ¹⁸

Residents must feel comfortable managing acute agitation in the ED to proceed with their assessment and be able to write treatment orders that may involve the need for ongoing chemical and/or mechanical restraint. Staff and residents need to be aware of region-specific medico-legal considerations and institutionally specified protocols. Treatment capacity is not always able to be fully assessed in the ED, and often medication is used to manage behaviour. Medication may be taken voluntarily or administered by means of emergency treatment or chemical restraint. In jurisdictions where there are insufficient acute inpatient beds and patients spend prolonged periods in the ED, we would recommend an assessment of capacity and the initiation of regular treatment in the ED. At times, the agitated patient may not immediately respond to interventions in the ED. A Code White should be called for added assistance at any time. Should an assault occur, the incident should be documented, and a process for debriefing and review should be initiated immediately. Residents will have support from their training programs, their department, and the hospital.

Risk Assessment

Risk assessment is an important part of every psychiatric assessment, and even more so in the ED. Fifty percent of people who die by suicide visit an ED in the year before their death. ¹⁹ Correspondingly, many ED referrals to psychiatry are for an assessment of suicide risk. The emergency psychiatrist is ultimately in the position of determining whether the patient is safe for discharge or requires admission on a voluntary or involuntary basis. Determination of suicide risk encompasses a complex range of diagnoses, demographic factors, distal and proximal psychosocial contributors, and clinical presentations. Because the exact prediction of a later suicide of an individual patient is not achievable with current methods, residents should instead focus on consistent risk assessment practices. Newer approaches to suicide risk assessment include both the “risk status” (i.e., the patient's risk compared to the general population) and the “risk state” (i.e., the patient's risk compared to his or her own personal baseline). ²⁰ As a crucial means of communication, documentation must clearly assess risk as part of the final impression, be it chronic or acute, and the plan should follow accordingly. The need for specific documentation in this regard cannot be overemphasized—this will be the only record should a suicide occur after the ED visit. ²¹

Patients with suicidal ideation will be referred, following an attempt or in a state that has the emergency physician concerned about the possibility of suicide as an outcome. More than 90 per cent of patients who die by suicide have a known psychiatric illness, ²² and the psychiatrist may be in the best position to determine what illness could be contributing to the presentation and what the options are for treatment. Interventions must target modifiable risk factors, and treat the underlying illness, while addressing substance use. Other approaches will be therapeutic in nature, using psychotherapy techniques. Psychoeducation regarding mindfulness, emotional regulation, and distress tolerance, as noted in the dialectical behaviour therapy (DBT) literature, is particularly helpful for chronically suicidal patients. ²³ When possible, the option of an emergency hold to reassess the suicide risk once the immediate crisis settles is ideal and can be therapeutic for the patient.

A detailed interview and structured risk assessment remain the gold standard for suicide risk assessment. There is no single correct approach, and residents can refer to guidelines published by several countries and organizations on risk assessment. Residents must be comfortable questioning directly about suicide in all emergency assessments and can be reassured that there is no iatrogenic risk with asking such questions. All learners must be able to perform and document a detailed risk assessment. Collateral information should be obtained whenever possible and is often essential in determining risk, especially when the patient is less than forthcoming, minimizing symptoms, or unable to attend the interview. Risk impression should be clearly communicated to other care providers and, with consent, to family and/or social supports.

Evidence-based suicide interventions should be considered as part of the ED clinical encounter. Safety planning can be part of the emergency visit and is a collaborative process between the patient and the emergency psychiatry team prior to discharge. Safety plans should not be confused with “no-harm contracts” which do not replace a full suicide risk assessment and are not recommended. Safety plans are supported by randomized control trial evidence showing a reduction in future suicide attempts. The safety plan is an element of the discharge process once that decision has been made and provides a readily accessible list of emergency contacts and therapeutic approaches to crisis management should the patient feel distressed and at risk after leaving the hospital. Brief contact interventions (scheduled phone calls or texts after ED discharge) and postcrisis follow-up care (outpatient appointments) are dependent on resources in a given region but have shown promising results in reducing suicidal behaviour. Means restriction can be accomplished by discussions that can be undertaken by a resident that involves ways a patient can make their environment safer, including reducing stockpiled medications or other dangerous items. Firearm-related deaths are the third leading cause of suicide in Canada (16 per cent of suicides) yet access to firearms is not often asked about in ED assessments and represents a good target for means restriction efforts. ²⁴ Psychotherapy that targets suicidal behaviours, such as DBT or cognitive behavioural therapy for suicide attempts, should be considered in outpatient follow-up.

Patients with borderline personality disorder (BPD) are likely to seek emergency care during acute crises, often involving self-injury and suicidality. Compared to depression-matched counterparts, patients with BPD exhibit higher ED attendance rates and are more likely to present with complex needs including substance use and psychiatric comorbidities. ²⁵ Addressing suicidal ideation in these individuals requires a holistic approach that combines acute crisis intervention, education, psychotherapy, and ongoing support. Providing education about BPD, its symptoms, prognosis, and treatment options, can help reduce stigma and enhance treatment engagement. Building a therapeutic alliance grounded in empathy, collaboration, and validation is key to fostering recovery and mitigating the risk of self-harm. DBT recommendations are especially relevant for this patient population.

Given the low base rate of events, the ability to predict future violence faces similar challenges to that of suicide risk. Fortunately, many of the considerations and techniques outlined above can be used to guide violence risk assessment with additional attention to empirically validated risk factors for violence and to balancing confidentiality with a potential duty to warn, inform, or protect. Residents should familiarize themselves with current literature regarding the epidemiology of physical and psychological violence, including threats, as well as the rates of victimization among those with psychiatric disorders. A systematic approach to assessment and documentation, taking a biopsychosocial perspective that outlines historical and clinical risk factors as well as areas to mitigate potential risk should be included. ²⁶ A history of previous violent behaviour, verbalized threats or fantasies, acute psychiatric symptoms (particularly hallucinations and delusions),^27–29 personality disorders, and untreated substance use disorders should be given special attention. ³⁰ When completed and documented, results of the risk assessment should be communicated to other relevant care providers, which can occur through a variety of mechanisms, including during handover, specific safety huddles with multidisciplinary staff, and through risk flagging opportunities within the medical record. It may also be prudent to discuss suicide and/or violence risk with patient families, depending on the level of risk and consent obtained.

Failure to conduct or document an appropriate and thorough suicide or violence risk assessment is the most common cause of liability in psychiatry. ³¹ As such, the importance of structured clinical risk assessment cannot be overstated.

Substance-Related Presentations

ED visits for substance use disorders are increasing in many Canadian provinces,^4,32 and substance use presentations can occur alone or with other psychiatric difficulties. Upwards of one-third of people with psychiatric illness have comorbid substance use pathology. ³³

Residents must recognize the risk of developing serious mental illness such as schizophrenia or bipolar 1 disorder after cannabis- or methamphetamine-induced psychosis and provide appropriate treatment and referrals.^34,35

Ideally, referrals from the ED to psychiatry should be made to assist with risk assessment, diagnosis, or management when the patient is not acutely intoxicated and is clinically able to participate in the assessment. However, patients will often be referred prior to full detoxification, making negotiations for the most appropriate time for a psychiatric assessment challenging for residents. Standardized scales, such as the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised can help assess withdrawal severity and progression.^36,37 The Hack Impairment Index can be used as an objective clinical measure of impairment in alcohol intoxication and is increasingly used in the US.^38,39 The Canadian Medical Protective Association provides guidance on detaining the intoxicated patient until a proper assessment can be completed without necessarily invoking involuntary certification. ⁴⁰

EDs often defer the decision for toxicology testing to the psychiatric team. Psychiatry may opt for a toxicology screen under particular circumstances: unknown substances ingested, clinical presentation not in keeping with the reported substances, or substance-related psychiatric illness.

The evaluation of patients with comorbid substance use and psychiatric illness may rely on a review of past presentations, time course of symptoms, and collateral history. All residents should be able to assess the patient's motivation for change and demonstrate basic motivational interviewing skills. ⁴¹ All patients motivated for change should be referred to the appropriate addiction resource.

Opioid-related deaths in Canada continued to rise from 2016 to 2022 and more than half of fatalities and hospital presentations involved comorbid stimulant use. ⁴² It is essential for physicians to have knowledge of treatment options for opioid use disorder, opioid withdrawal in acute care settings, harm reduction strategies, and safety protocols. Polysubstance use including concurrent use of opioids, BZDs, alcohol, and stimulants can increase the risk of complicated withdrawal. Emergency psychiatry providers may work closely with addiction services in the management of complex presentations.

Education in this area should continue well past residency due to the ever-expanding list of substances available on the streets and the internet.

Medically Complex Presentations

Medical comorbidity is common and contributes to the complexity of assessing patients in the ED. Psychiatric patients have higher rates of medical disorders than the general population; they are hospitalized for medical causes more often, for longer duration, and visit the ED more frequently than people without mental disorders. ⁴³ Physical examination and vitals are often inconsistently performed by emergency physicians and nurses on ED patients with psychiatric presentations. This higher vulnerability to physical illness is compounded by a variety of exacerbating factors: patients may not have a family physician or follow-up with medical care; social determinants of care such as poverty and housing instability may inhibit preventative health care; psychotropic medications may have significant medical side effects; and physicians may attribute symptoms to the psychiatric illness and not adequately screen for medical comorbidities.^44,45 These considerations reinforce the need for the resident in the ED to maintain vigilance in their holistic assessment of each patient, to ensure a comprehensive assessment of current and past medical history, and to re-evaluate a thorough list of differential diagnoses.

There is significant literature about medical stability (a term preferable to medical clearance), and no one definition exists. ⁴⁶ As a result, educating trainees about the medically complex patient population in the ED is challenging. In addition, the threshold at which one deems a patient medically stable will vary depending on the facility, the medical support available, and the time of day. Trainees need to be aware of the policies of the hospital in which they work, specifically regarding the approach to consultation, should an acute medical problem be discovered.

The medically complex patient underscores the importance of collaborative work in the ED. Historically there has been a tendency for psychiatry and other medical specialties to work in silos, with different “sides” wary of taking ownership of patients for fear of a serious outcome occurring that would be out of the scope of one's practice. As such, psychiatric teams in ED have at times required unnecessary investigations and unwarranted levels of “clearance” prior to accepting consultations or admissions. While the medical safety of patients is crucial, residents and psychiatrists should keep in mind that medical comorbidity is common but that emergent life-threatening conditions are rare. Delaying psychiatric admissions for medical investigations or treatment that can be done on the ward creates disrupting backup and adds discomfort to the patient who may have to spend more time in the ED. In general, lab investigations and urine drug screens on psychiatric patients performed in the ED do not alter disposition, a patient's subjective history of their physical complaint often correlates with abnormal findings on work-up, and routine brain imaging (computed tomography or magnetic resonance imaging) in psychotic presentations is very unlikely to uncover a physical disease process causing the psychotic symptoms.^47,48

Among patients presenting to the ED with mental health as the primary presenting issue, if vitals are within normal range, and there is no acute physical complaint, standard history and physical exam by the emergency physician is generally sufficient to declare medical stability. The American Association for Emergency Task Force on Medical Clearance of Adults provides additional recommendations for medical clearance based on specific patient presentations, such as new-onset psychiatric symptoms in individuals over age 45. ⁴⁹ Psychiatry teams in the ED should be judicious when advocating for additional medical work-up or medical transfer, with such decisions specific to each patient rather than routine. Discussion with the referring physician is paramount in determining the specifics of medical stability. Navigating these interprofessional communications can be challenging, particularly if the reason for referring a patient is vague or the issue is a contentious one between services. Delirium and dementia are two examples of diagnoses that can strain the relationship between specialty services, thus residents may require assistance in developing skills to negotiate care for these patients.

Equity and Intersectionality in Emergency Psychiatry

Patients with mental illness and substance use disorders, particularly those with intersecting individual and structural vulnerabilities, experience worse health outcomes than the general population. Inequity results from intersecting systems of power and privilege, including structural stigma, racism, sexism, ableism, and socioeconomic status (SES).^50,51 Understanding patients from an intersectional lens is important to delivering compassionate care and addressing root causes of inequity in emergency psychiatry. For example, a patient may be labelled as “noncompliant” due to treatment nonadherence because they are unable to engage with discharge recommendations due to intersecting structural factors.

In emergency psychiatry, racism, both individual and structural, leads to poorer mental health outcomes, including higher rates of depression and suicide, and increased use of restraints.^52–57 Indigenous patients experience high rates of racism in Canadian EDs, leading to poor or inadequate treatment and higher mortality.^58,59 Furthermore, each individual will experience racism differently based on other aspects of their identity, including unearned advantages (privilege, i.e., heterosexual, able-bodied) or disadvantages (oppression, i.e., female, lower SES). ⁶⁰

Patients with multiple marginalized identities are more likely to have trauma-related symptoms. ⁶¹ Implementing trauma-informed care principles at the individual and system level can help mitigate retraumatization.^62,63 For example, a trainee may advocate for a trauma-informed approach for a female victim of sexual trauma who may be further traumatized by being secluded, restrained, or having male protective services personnel intervene in their care.

Residency programs should provide education on structural competency, cultural humility, trauma-informed care, and advocacy early in training.^64–67 Understanding how intersectional and structural factors impact emergency psychiatry presentations is critical to delivering high-quality care and reducing burnout. ⁶⁸

Learner Wellness in Emergency Psychiatry

In emergency psychiatry, learner wellness requires unique considerations. Residents are at increased risk for depression and trauma-related disorders due to workplace trauma exposure and are more likely to witness critical incidents and adverse outcomes, including suicide.^69,70 Prolonged working hours, high patient volume, and incivility in the ED can compound these risks. ⁷¹ The lack of human and environmental resources further reduces access to high-quality, evidence-based mental health care and can lead to moral distress.

Despite increased messaging around wellness in residency programs, the hidden curriculum of physician invincibility, which denies personal physical and mental health needs, remains a challenge. Possible wellness interventions include sustainable learner duty hours, regular check-ins, supervisor modelling of vulnerability, inclusion in critical incident debriefing, and time to recover from involvement in critical incidents.^72–74 Programs can measure learner wellness and monitor the impact of interventions regularly to ensure effectiveness.

Education in Emergency Psychiatry

Education in emergency psychiatry begins with the undergraduate medical curriculum, during either preclinical lectures or clinical rotations in psychiatry. Little evidence exists to provide guidance about the timing or content of this training, but common sense would dictate that initial exposure to the assessment of patients and safety aspects occurs prior to the clinical clerkship years. Novel teaching strategies, using standardized patients and role-playing, increase comfort with assessing and treating patients in crisis while decreasing learner anxiety.^75,76 Some evidence also exists to support independent case-based studies in emergency psychiatry for medical students as a means of improving test scores. ⁷⁷ During the clerkship, exposure to emergency psychiatry settings is suggested, either during the on-call period or as part of a core clerkship rotation. At a minimum, clerks should develop an awareness of common emergency psychiatric presentations, an understanding of the use of mechanical and chemical restraint, sensitivity and decreased stigma regarding this patient population, and an understanding of local mental health acts that govern involuntary hospitalization and capacity. However, it is not expected that these concepts be mastered. As CBME becomes more clearly elucidated at the undergraduate level, specific EPAs can be designed in accordance with the Medical Council of Canada's learning objectives.

Regarding postgraduate education, the RCPSC requires that psychiatry residents be able to identify and appropriately respond to clinical issues that arise from suicide, self-harm, or harm directed towards others. ⁶ Residents must be proficient in crisis intervention and de-escalation techniques as part of the CanMEDS medical expert role. Emergency psychiatric training sites are optimal for meeting these objectives, while also providing opportunities for residents to gain enhanced skills in the roles of advocate, collaborator, communicator, and leader. It is recommended by the RCPSC that there are clinical experiences in emergency psychiatry in Foundations of Discipline, Core of Discipline, and Transition to Practice. ⁷⁸ The AAEP recommends that a minimum of two months of dedicated emergency psychiatry clinical training occur in the first or second year to achieve competency to provide good care in crisis situations and across all settings. ⁷⁹

CBD is a multiyear transformational change initiative that was officially launched by the RCPSC in 2017, though psychiatry launched in 2020. ⁸⁰ To operationalize CBD, the RCPSC developed a framework of EPAs and milestones to guide learner assessment. EPAs are defined as “a unit of professional practice that can be fully entrusted to a trainee, as soon as they demonstrate the necessary competence to execute the activity unsupervised.” EPAs are tasks that can be accomplished; a unit of work that is observable and related to the work that a physician would perform. EPAs are further stratified according to the stage of training, with categories including transition to discipline, foundations of discipline, core of discipline, and transition to practice. For example, transition to discipline EPA #1 is “obtaining a psychiatric history to inform the preliminary diagnostic impression for patients presenting with mental disorders,” and core of discipline EPA #8 is “integrating the principles and skills of psychopharmacology into patient care.” The EPAs as a group are quite broad, and elements of each may pertain to emergency psychiatry.

Lastly, continuing medical education in emergency psychiatry is paramount. Both junior and senior staff require orientation to on-call policies and updates of emergency psychiatry skills.

Future Directions

Advancement continues in the field of emergency psychiatry. An updated national survey of residency programs yielded results from 16 out of 17 programs and provided insight into the state of education across the country. CBD has mandated a transition to CBME, and programs across the country grapple with the implementation of this new framework. Adaptation has been variable and clear benefits are yet to be realized. Program-specific educational leadership in emergency psychiatry may help advance these goals and highlight the excellent general psychiatry learning experience emergency work provides, as high volumes and diverse patient presentations lend themselves to opportunities for successfully demonstrating competence through EPAs. Notably, approximately half of the programs have an emergency psychiatry rotation or curriculum lead. While most (80 per cent) of the programs are making use of EPAs in the emergency setting, only 30 per cent are routinely using them for assessment in the on-call setting; utilizing EPAs on-call would highlight the learning opportunities and serve to elevate the educational experience of emergency psychiatry.

Since the 2004 and 2013 position papers, it remains evident that the practice and teaching of emergency psychiatry varies widely and is largely dependent on available resources, systems, and settings. Many programs include an urgent care setting or clinic as part of the emergency psychiatry rotation; as outpatient programs struggle with high volumes and long wait times, novel models of emergency psychiatric care are needed to ensure timely access to care beyond the ED.

There has been an increased recognition of intersectionality and the role that race, gender, ability, neurodiversity, and socioeconomic status play in psychiatric emergencies. Programs must train residents who are able to meet the diverse needs of the Canadian public. The educational curriculum should include formal teaching about racism and stigma and supporting Indigenous populations in the ED. Further, experiencing racism and stigma in the ED has a significant impact on all team members, and services must embody trauma-informed leadership aimed at ameliorating this distress, including debriefing where appropriate, regular check-ins, modelling vulnerability, and allowing time to recuperate after a critical incident.

Emergency psychiatry is a central, dynamic, and progressively relevant aspect of psychiatric practice. The ED remains a vital point of access for psychiatric care for many patients and is especially relied upon where traditional outpatient resources are scarce or not able to effectively meet demand. Increasingly, emergency psychiatry subsumes general psychiatry. Residents must receive robust training, in both on-call and daytime emergency settings, in both junior and senior years. The emergency setting provides an excellent opportunity to develop both foundational skills and support the transition to practice. Moving forward, psychiatrists must master this vital skill set to effectively meet the needs of the people we serve.