Qualitative study on the use of emergency services by people with serious mental disorder in Spain

The National Healthcare System in Spain has more than 50 million requests for emergency care each year. These are met in three organizational areas: primary care, mobile emergency services and hospital emergency departments (EDs). In Spain, anyone can choose freely and without economic cost what type of medical care they want to receive according to their subjective perception of symptoms severity. As a result, the average emergency department visits have been increasing over the last three decades [1, 2]. More than 50% of the Spanish population went to an emergency medical service in 2019 [3], mostly due to banal pathology [4]. Only during the first wave of the COVID-19 pandemic this number decreased generally [5].

The population with severe mental disorder (SMD) is a social group with greater demand for urgent medical attention than the general population, despite being assigned one or more mental health network resources [6‐8]. Psychiatric emergencies have been defined as acute disturbances of thought, behaviour, mood or social relationships that require immediate intervention as defined by the patient, the family or the social unit to save the patient and/or other people from imminent danger [9]. Situations of psychiatric decompensation can have devastating consequences for the ill people and their families, which is why it is a priority to stabilize the patient with SMD and prevent suicidal ideation [10]. However, most of the situations treated in the emergency services have not presented this seriousness and could have been resolved through routine medical care or better health education [6‐8, 11].

Crowded emergency medical services may compromise patient treatment satisfaction, contributing to increased health care costs promoting the appearance of high emergency department users [11]. We face a complex situation in which the demand for emergency care among this population is conditioned not only by the physical and mental health status, but also for a wide range of socioeconomic and demographic factors that cannot be addressed exclusively by the organization of emergency services [12]. People at risk of social exclusion, with high rates of poverty and unemployment, and those who live in rural areas, with social isolation, decide to go to the emergency services more frequently [13]. Similarly, the care provided by family members to people with MDS in Spanish society is very important and decisive when choosing to go to an emergency department [7].

Knowledge of the current socioeconomic context, the family support and the biopsychosocial circumstances that accompany and cause the frequentation of the emergency department by the population with SMD would make it possible to rethink the healthcare offer and better adapt the resources [12]. The objective of this study was to gain a holistic understanding of the needs of SMD patients and their main caregivers in situations requiring emergency medical care.

Twenty-one patient/caregiver paired interviews have been carried out with a total of 42 participants and a mean duration of 19 min (± SD 7.2) (range 5–33 min). The patients had diagnoses of schizophrenia (38%), bipolar disorder (31%) and major depression (31%), with a mean age of 58.8 years (± SD 13.1), 63% were women, 32% were disabled and 25% had poor family function. The caregivers were first-degree family members (50% spouses, 31% sons and/or daughters, 13% siblings and 6% parents), 53% were men and the mean age was 52.9 years (± DS 16.9), 60% showed caregiving burden and 32% perceived family dysfunction. The characteristics according to an urban or a rural area are shown in Table 2. The data collected is presented in three categories and nine subcategories (Fig. 2 and Table 3) corresponding to the topics of the interview script, the hypotheses generated and the explanatory framework.

The urgent demand for care arises after a self-diagnosis made by the patient with SMD and/or his or her caregiver when noticing loss of health. This urgent need for care depends not only on symptoms related to mental health, but also on the quality of self-care, accessibility and continuity of healthcare and social support [14, 15]. Equally important is the knowledge of the range of health resources available to these patients who have socially normalized the use of hospital emergency departments due to the lack of health education and a culture where people are used to receiving immediate care in a hospital [4, 15, 16]. Going to an emergency department for lack of other resources would compensate for the inequalities and social inequities experienced by this population, but it does not take into account ethical or economic aspects, underestimates the importance of the decision of healthcare professionals [12] and does not ensure adequate continuity of care [17].

The feeling of isolation and lack of resources is much more pronounced in rural than in urban areas [13]. Loneliness within the family and society results from the loss of social ties due to the stigma of the mental illness, causing family and social networks to become less close and more fragile, which overburden the caregiver. Institutional isolation and the lack of information on health resources is greater than in urban areas and create a reality of contexts to be intervened by social and healthcare services [13]. Avoiding unnecessary visits to the emergency department involves improving accessibility and outpatient monitoring, with a more accessible healthcare network to deal with unexpected situations [18]. In this sense, telemedicine is a possible and accepted approach for this population that would help to address the urgent needs of patients, families and communities, especially in rural areas [19, 20]. Spain has already had successful experiences with the introduction of preferential telephone care services for people with SMD, which have improved communication and access to mental health resources. Caregivers do not ask for direct and exclusive access to the psychiatrist, but rather to a professional who can guide them in difficult times and facilitate continuity of care in Mental Health. This type of telematic care has shown greater efficiency and accessibility, reduction of waiting times and unnecessary psychiatric hospitalizations along with high levels of patient satisfaction [20, 21].

Despite adequate training of the physicians to attend to urgent situations [22], improvements in staffing levels and structural and care network reforms of the hospital EDs over the past few decades [6, 12, 23], there are still problems of overcrowding due to the increase in urgent demand. In the case of the population with SMD, the hospital response cannot completely resolve all the needs detected [16, 23]. Nevertheless, some aspects, such as waiting times for medical care or prioritizing care over other trivial problems, would improve the perception of the quality of emergency care [24].

Qualitative study limitations may difficult to to generalise the results to other settings with different cultural and socio-economic characteristics. The results obtained from a convenience sample would only apply to populations with similar characteristics to the ones that have been studied. Opinions of health professionals, institutionalized patients or those who live alone were not collected due to the objective of the study and the characteristics of the recruitment. The results obtained may be affected by the possible presence of a selection bias, by not including all diagnostic categories of severe mental disorders, and a social desirability bias.

Nevertheless, it is important to highlight the experiences of people in rural areas and the ones at risk of social exclusion because of their greater vulnerability and higher rates of emergency service use [12, 13, 24]. On the other hand, the social health situation generated by the COVID-19 pandemic provides a different panorama in a population that is more vulnerable but hesitant to go to the emergency department out of fear of contagion [5, 25]. The pandemic situation has modified the circumstances of emergency care, generating greater saturation and delays which can lead to dissatisfaction and violation of the patient’s privacy [12].

The management measures adopted from the emergency services themselves have been insufficient to reduce demand for urgent medical care [7‐9]. For this reason, it is necessary to carry out studies on the usefulness of the collaborative coordination in care transitions between emergency services and primary care [23] and the innovation for medical access through use of technology as telephone consultations [26, 27]. Future research should study the impact of improving complex social elements [28], such as emotional support for caregivers or increasing the close social network, in order to improve self-care of this population [29]. It is equally important to know the efficiency of improving the early detection of mental pathology, an additional support systems and the access to alternative healthcare resources for this population group as more efficient options for resolving situations perceived as urgent [9, 12, 26, 30].

Reducing unnecessary emergency department visits should be a goal of all primary care and mental health services. Unnecessary urgent medical care demand burden the health care system as they are costly and consume resources that other individuals with more acute needs may need. Experiences and needs of patients with SMD and their caregivers, both in terms of prompt care and in terms of proximity, confidentiality and privacy, are the key to knowing the areas for improvement. In addition to changes in healthcare management, it is a priority to promote community participation to assess and address social determinants of health and health disparities. These options include the implementation of community resources, the personalized support for caregivers and the improvement of social cohesion networks. The experiences and needs revealed in this study offer a community diagnosis that would allow the adaptation of the supply to the real needs of emergency care and promote solutions without relying exclusively on emergency services. A holistic approach of different multidisciplinary solutions to manage emergencies in patients with SMD would promote rational use of healthcare resources and better healthcare outcomes.