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Crisis facilities provide a safe and therapeutic alternative to emergency departments and jails for people experiencing behavioral health emergencies. Program design should center around customer needs which include individuals and families in crisis and key community stakeholders like first responders. Ideally, a crisis system should be organized into a broad continuum of services that ensures care is provided in the least restrictive setting, even for people with high acuity needs, and stakeholders should have a clear understanding of the capabilities of each component facility and the population it can safely serve. This paper provides a framework to help policymakers achieve this goal.

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This work expands on the National Council for Mental Wellbeing whitepaper Quality Measurement in Crisis Services. The authors present 2 approaches to measure development: The first maps flow through the crisis continuum and defines metrics for each step of the process. The second uses the mnemonic ACCESS TO HELP to define system values, from the perspective of various stakeholders, with corresponding metrics. The article also includes case examples and discusses how metrics can align multiple components of a crisis system toward common goals, strategies for using metrics to drive quality improvement initiatives, and the complexities of measuring and interpreting data.

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Current literature emphasizes the necessary and increasing role of the emergency department (ED) psychologist. This perspective paper will illustrate that the recent focus on an ED psychologist is necessary, but insufficient. Equally important, is an understanding of when a patient in a potential crisis does not require an ED admission, but rather an assessment that is made prior to the patient going to the ED. The essential role of an outpatient crisis team is vital in differentiating when an ED admission is indicated for a psychiatric crisis (true positive) and when an ED admission is not indicated for a psychiatric crisis (false positive). Evaluating crises prior to ED admissions accomplishes two critical healthcare objectives in a parallel process: 1) accurately assessing the proper level of care needed when a patient reports they are experiencing acute psychiatric symptoms (which may or may not necessitate emergency department level of care, and 2) reducing burden on an already over-extended ED when emergency care is not indicated. Our findings are uniquely drawn from a highly diverse youth patient population in Northern California, United States.

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Suicide substantially impacts disaster-affected communities due to pre-existing psychosocial effects caused by the disaster. Following the Great East Japan Earthquake of 2011, local disaster aid workers had overworked for months, and many workers eventually died by suicide. Although many workplaces suffered this dual damage, there is limited literature on psychosocial postvention in this context. This study reports the activities of individual/group postventions provided to these aid workers. The bereaved person expressed grief for the loss of their colleagues and anger for not being protected. The postvention observed unusual and distinctive group dynamics. It was essential for mental health professionals to address 2 types of traumatic exposures in the group programs -trauma from the disaster and their colleagues' deaths due to suicide. These postvention programs might be beneficial in maintaining aid workers' mental health and helping them cope with the loss of their colleagues.

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Objective: This scoping review aims to characterize what is known about transgender and gender diverse (TGD) individuals in emergency psychiatric settings and identify what gaps persist in this literature. Methods: A search of 4 electronic databases (PubMed, Web of Science, GenderWatch, and PsycINFO) was used for data collection. Included were studies that looked at TGD individuals presenting to a psychiatric emergency department (ED) or ED with a primary mental health concern. Study screening progress was documented in a Preferred Reporting Items for Systematic reviews and Meta-Analyses flow chart. A total of 232 titles and abstracts were screened, 38 full texts were evaluated for eligibility, and 10 studies were included. Results: The studies reviewed identified mental health vulnerabilities unique to the TGD population, including service denial in health care settings, gender dysphoria, increased rates of non-suicidal self-injury, and in some studies an increase in suicidality. Societal inequities, including the risk of discrimination and residential instability, were also revealed. A subset of the studies identified best practices in caring for this population, including the use of non-judgmental, affirmative, and inclusive language, and on a structural level creating emergency environments that are confidential, inclusive, and therapeutic for these individuals. Conclusions: There is limited information on TGD individuals in emergency psychiatric settings, and thus it is difficult to form strong conclusions. However, the current evidence available suggests possible inequities in this population. Three major themes with regards to TGD individuals in emergency psychiatric settings were identified: mental health vulnerabilities, societal inequities, and best practices in caring for this population. Overall, there is a scarcity of literature in this field, and further research on the experiences of this population is needed to inform clinical practice.

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OBJECTIVE: To compare psychiatric emergencies and self-harm at emergency departments (EDs) 1 year into the pandemic, to early pandemic and pre-pandemic, and to examine the changes in the characteristics of self-harm presentations. METHOD: This retrospective cohort study expanded on the Pandemic-Related Emergency Psychiatric Presentations (PREP-kids) study. Routine record data in March to April of 2019, 2020, and 2021 from 62 EDs in 25 countries were included. ED presentations made by children and adolescents for any mental health reasons were analyzed. RESULTS: Altogether, 8,174 psychiatric presentations were recorded (63.5% female; mean [SD] age, 14.3 [2.6] years), 3,742 of which were self-harm presentations. Rate of psychiatric ED presentations in March to April 2021 was twice as high as in March to April 2020 (incidence rate ratio [IRR], 1.93; 95% CI, 1.60-2.33), and 50% higher than in March to April 2019 (IRR, 1.51; 95% CI, 1.25-1.81). Rate of self-harm presentations doubled between March to April 2020 and March to April 2021 (IRR, 1.98; 95% CI, 1.68-2.34), and was overall 1.7 times higher than in March to April 2019 (IRR, 1.70; 95% CI, 1.44-2.00). Comparing self-harm characteristics in March to April 2021 with March to April 2019, self-harm contributed to a higher proportion of all psychiatric presentations (odds ratio [OR], 1.30; 95% CI, 1.05-1.62), whereas female representation in self-harm presentations doubled (OR, 1.98; 95% CI, 1.45-2.72) and follow-up appointments were offered 4 times as often (OR, 4.46; 95% CI, 2.32-8.58). CONCLUSION: Increased pediatric ED visits for both self-harm and psychiatric reasons were observed, suggesting potential deterioration in child mental health. Self-harm in girls possibly increased and needs to be prioritized. Clinical services should continue using follow-up appointments to support discharge from EDs. DIVERSITY & INCLUSION STATEMENT: One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

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Purpose: The death of a close family member is commonly accompanied by intense grief, stress, and loss of social support. We hypothesized that recent bereavement would be associated with an increase in symptom exacerbations among adults with serious mental illness (SMI) whose partners or parents had died. Patients and Methods: Adults whose partners and parents had died in Denmark between January 1, 2010, and June 30, 2016, were identified using linked population-based registries. History of SMI was defined as having a diagnosis of schizophrenia and schizoaffective disorders, major depression, and bipolar disorder in the five years preceding their family member's death in the Danish Psychiatric Central Research Register using International Classification of Diseases-10 codes. The odds of SMI exacerbation (ie, attempt or completion of suicide or psychiatric hospitalization) among partners and children in the first two years after death in 3-month intervals were estimated with generalized estimating equations. Results: 12.8% of partners and 15.0% of adult children with a history of SMI experienced any SMI exacerbation two years after bereavement. Among bereaved partners, older age (80+ years) was associated with a lower risk of experiencing an SMI exacerbation compared with partners aged 18-49 years (ORadj=0.29, [0.18-0.45]). Partners with a history of SMI had significantly increased odds of SMI exacerbations three months after their partners' death compared to prior to their partners' death (ORadj = 1.43, [1.13-1.81]). There was no evidence that adult children with SMI experience increased SMI exacerbations after the death of their parents compared to prior to death. Conclusion: Adults with a history of SMI whose partners had died are at increased risk for an SMI exacerbation post bereavement. Additional bereavement resources and support should be provided to those with a history of SMI, especially in the period immediately after death.

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The purpose of this study was to compare the characteristics of suicide attempts by drug overdose between young people and adults, and evaluate the cost-effectiveness of a multi-disciplinary emergency consultation system (MECS) for suicide attempters with drug overdose. It was verified by comparing and analyzing data from June 1, 2017 to May 31, 2018 (before the MECS was implemented; pre-MECS), and from June 1, 2018 to May 31, 2019 (after the MECS was implemented; post-MECS). The data were retrospectively reviewed for a total of 251 such patients with suicide attempts by drug overdose who visited the emergency room of a university hospital in Seoul during the period. The young people group were shown to be more likely to use painkillers and less likely to use psychoactive drugs for a suicide attempt (p < 0.01), had more unplanned attempts than planned ones (p < 0.01), and had lower levels of intentionality for suicide (p = 0.04) and of suicide lethality (p = 0.02), compared to the adult group. We defined suicide attempts as being "serious" when there was both high intentionality and lethality. On this basis, the young people group had less serious suicide attempts, compared to the adult group (p = 0.02). Young people in the post-MECS group had lower intensive care unit (ICU) costs (p = 0.01) and lower costs in the 6-months after the suicide attempt (p = 0.02) compared to those in the pre-MECS group. Young people, both with serious (p < 0.01) and non-serious attempts (p < 0.01) in the post-MECS group had lower ICU costs compared to those in the pre-MECS group. Adults with non-serious attempts in the post-MECS group had lower ICU costs (p < 0.01) compared to those in the pre-MECS group. Therefore, it can be concluded that fast and precise cooperation from the multidisciplinary departments for patients who attempted suicide by drug overdose reduced unnecessary ICU treatment and costs, especially in young attempters and those with lower levels of intentionality and lethality.

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Background: Florida law defines emergency treatment orders (ETOs) as an immediate administration of psychotropic medications to a person to expeditiously treat symptoms that may present an immediate danger to the safety of the person or others.1 There is currently little information on who receives ETOs. In this study, we aim to explore correlations between patients' demographics and administering ETOs in order to understand this cohort, which could allow for improved services and alternative interventions. Methods: This retrospective study examined data from 1,460 adult patients who were admitted to an acute inpatient psychiatric unit from January 2015 to December 2017 and who received at least one ETO during their hospital admission. Results: Results revealed that younger patients (18-25 years) were at increased risk of receiving more than one ETO (p=0.039) than patients who were 26 and older. Patients with an elevated body mass index (BMI) (25 kg/m2 or more) also had a significantly increased likelihood of being administered more ETOs (≥4 ETOs) than patients with a lower BMI (defined as less than 25 kg/m2 [p=0.037]). Moreover, patients with a length of stay (LOS) of more than 14 days were more likely to receive more ETOs compared to patients with LOS less than or equal to 14 days (p<0.001). Lastly, patients with a neurocognitive disorder and/or within the schizophrenia spectrum or other psychotic disorders were more likely to receive ETOs (p<0.001) than patients with other diagnoses. Conclusion: There are some correlations in administering ETOs in that younger patients with an elevated BMI, longer LOS and certain diagnoses receive more ETOs. The reason for these findings is not clear. Therefore, prospective studies should be conducted in order to analyze these correlations.

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This descriptive record-based study included 75 patients who had engaged in domestic property damaging (DPD) and needed assessment by an urban emergency psychiatric service team in The Netherlands. The DPD patients were compared to 1145 other patients referred because of aggression, suicidality or other reasons. DPD patients were more often diagnosed with a psychotic disorder or a manic episode, had more often a migration background, were less often diagnosed with depression, and had lower GAF scores. There were no differences with respect to personality disorders or substance use. DPD patients were two to six times more likely to be (mostly involuntarily) admitted to a psychiatric department (64%), than the other patient groups (aggression 45%, suicidality 21%, other referral reasons 37%). The findings indicate that DPD patients represent an exclusive group who possibly have more intercultural and communication disadvantages due to less cultural acceptance or lack of knowledge about mental healthcare in the Netherlands.

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As police officers are often the first responders to mental health crises, a number of approaches have emerged to support skilled police crisis responses. One such approach is the police-mental health co-responding team model, whereby mental health nurses and police officers jointly respond to mental health crises in the community. In the present mixed-method study, we evaluated outcomes of co-responding team interactions at a large Canadian urban centre by analysing administrative data for 2743 such interactions, and where comparison data were available, compared them to 16 226 police-only team responses. To understand service user experiences, we recruited 15 service users for in-depth qualitative interviews, and completed inductive thematic analysis. Co-responding team interactions had low rates of injury and arrest, and compared to police-only teams, co-responding teams had higher overall rates of escorts to hospital, but lower rates of involuntary escorts. Co-responding teams also spent less time on hospital handovers than police-only teams. Service users valued responders with mental health knowledge and verbal de-escalation skills, as well as a compassionate, empowering, and non-criminalizing approach. Current findings suggest that co-responding teams could be a useful component of existing crisis-response systems.

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The way service seekers interact with the staff at emergency services has been shown to influence the standard of care, especially in the case of certain psychiatric manifestations. Staff reactions to psychiatric complaints have been linked to their comfort dealing with these types of service users as well as their competencies understanding the illness. It is therefore vital to understand which skills increase confidence in treating psychiatric emergencies. Twenty-six open-ended convergent interviews were conducted with staff working in a psychiatric emergency department. Thematic analysis was used to analyze the data. Participants reported several non-technical skills which developed from exclusively serving people with psychiatric emergencies: 1) Vigilance allowed staff to be sensitive to minor changes in behavior which precede psychiatric emergencies. 2) The ability to negotiate and find tangible solutions was particularly important when dealing with psychiatric complaints which may not have tangible resolutions. 3) The ability to appraise social support networks allowed staff to plan follow-up actions and ensure continuity of care when support was available. 4) The ability to self-reflect allowed participants to learn from their experience and avoid burnout, frustration, and fatigue. Participants also reported several other clinical skills which they gained during training, including teamwork, de-escalating techniques and risk assessment. Tentatively speaking, these skills improve staff's confidence when treating psychiatric emergencies. Certain skills may be generalized to staff working in medical emergency departments who frequently encounter psychiatric complaints.

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OBJECTIVES: Despite efforts to restructure mental health (MH) services across Victoria, the social and economic burden of MH illness continues to grow. This study compares MH presentations to EDs with a study undertaken 10 years earlier. METHODS: The article is a retrospective observational study of MH presentations to four Victorian EDs between May and October 2013. Subjects were included if the presentation was MH related as determined by an International Classification of Diseases (version 10) discharge diagnosis, they were referred to an emergency crisis assessment team or had a documented presenting psychiatric complaint. Variables were extracted from electronic medical records and compared with 2004 data from a previous published study. RESULTS: There were 5659 MH presentations over the 5 months compared with 2788 in 2004. The median ED length of stay decreased from 4:18 h in 2004 to 3:20 h in 2013 (P < 0.001), with a significant reduction in length of stay >4 h from 52.5% to 35.4% (P < 0.001). There was a 22-fold increase in short stay units as discharge destination from 0.9% to 20.2% (P < 0.001). Patients presenting with concurrent methamphetamine exposure doubled from 2.2% of presentations to 4.3% (P < 0.001). CONCLUSION: Despite increasing MH-related presentations, changes in ED practice have allowed improvements in delivery of care through a shortened ED length of stay and the virtual elimination of very long stays over 24 h. However, there continues to be significant variability in management and performance across hospital sites. Identifying which interventions lead to standout site performance, and subsequent application more broadly, may improve future ED delivery of care.