Psychiatric Quarterly

, Volume 90, Issue 4, pp 703–716 | Cite as

Reasons for Emergency Department Use among Patients with Mental Disorders

  • Marie-Josée FleuryEmail author
  • Guy Grenier
  • Lambert Farand
  • Francine Ferland
Original Paper


Disproportionate use of emergency departments (EDs) by patients with mental disorders suggests the need to evaluate factors associated with ED use. Based on the Andersen Behavioral model, this mixed-method study identified the contributions of predisposing, enabling and needs factors in ED use among 328 patients with mental disorders. We hypothesised that ED use for mental health (MH) reasons would be most strongly associated with need factors. The study was conducted in four EDs located in different territories of Quebec (Canada). ED teams assisted with patient recruitment. Participants completed a questionnaire including a qualitative component on reasons for using the ED and assessments of ED and MH services. Data were organised according to the Andersen model, and analysed thematically. ED users were generally single, with low socioeconomic status and inadequate knowledge of MH services (predisposing factors). Most had a regular source of care which facilitated ED referrals (enabling factors); although inadequate access to outpatient care contributed to ED use. Needs factors were the primary motivators in ED use among patients with mental disorders, especially self-rated importance of problems, and MH diagnoses including suicidal ideation/attempts, depression, anxiety, and substance use disorders. Results confirmed our hypothesis that ED visits were more strongly related to needs factors. The mixed methodology reinforced the importance of predisposing and enabling factors in ED use, particularly in more complex cases. Various strategies (e.g. shared care, recruitment of addiction liaison nurses for SUD screening) are suggested for improving access to other resources and reducing non-urgent ED use.


Emergency department Mental disorders Mixed method study Patient perspective Utilization factors 



This study was funded by the Fonds de la recherche en santé du Québec (FRSQ), grant number 3082. We thank the ED users who participated in this research. We are also grateful to Judith Sabetti for her assistance.

Compliance with Ethical Standards

Conflict of Interest

The authors declare they have no conflicts of interest.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Barratt H, Rojas-Garcia A, Clarke K, Moore A, Whittington C, Stockton S, et al. Epidemiology of mental health attendances at emergency departments: systematic review and meta-analysis. PLoS One. 2016;11(4):e0154449. Scholar
  2. 2.
    Clarke D, Usick R, Sanderson A, Giles-Smith L, Baker J. Emergency department staff attitudes towards mental health consumers: a literature review and thematic content analysis. Int J Ment Health Nurs. 2014;23(3):273–84. Scholar
  3. 3.
    Clarke DE, Dusome D, Hughes L. Emergency department from the mental health client's perspective. Int J Ment Health Nurs. 2007;16(2):126–31. Scholar
  4. 4.
    Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med. 2014;15(1):1–6. Scholar
  5. 5.
    Ayangbayi T, Okunade A, Karakus M, Nianogo T. Characteristics of hospital emergency room visits for mental and substance use disorders. Psychiatr Serv. 2017;68(4):408–10. Scholar
  6. 6.
    Minassian A, Vilke GM, Wilson MP. Frequent emergency department visits are more prevalent in psychiatric, alcohol abuse, and dual diagnosis conditions than in chronic viral illnesses such as hepatitis and human immunodeficiency virus. J Emerg Med. 2013;45(4):520–5. Scholar
  7. 7.
    Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1–10.CrossRefGoogle Scholar
  8. 8.
    Gasperini B, Cherubini A, Pierri F, Barbadoro P, Fedecostante M, Prospero E. Potentially preventable visits to the emergency department in older adults: results from a national survey in Italy. PLoS One. 2017;12(12):e0189925. Scholar
  9. 9.
    Doran KM, Shumway M, Hoff RA, Blackstock OJ, Dilworth SE, Riley ED. Correlates of hospital use in homeless and unstably housed women: the role of physical health and pain. Womens Health Issues. 2014;24(5):535–41. Scholar
  10. 10.
    Parkman T, Neale J, Day E, Drummond C. Qualitative exploration of why people repeatedly attend emergency departments for alcohol-related reasons. BMC Health Serv Res. 2017;17(1):140. Scholar
  11. 11.
    Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen's Behavioral Model of Health Services Use: a systematic review of studies from 1998–2011. Psychosoc Med. 2012;9:Doc11. doi:
  12. 12.
    Walsh PG, Currier GW, Shah MN, Friedman B. Older adults with mental disorders: what factors distinguish those who present to emergency departments for mental health reasons from those who do not? Am J Geriatr Psychiatry. 2015;23(11):1162–71. Scholar
  13. 13.
    Halmer TC, Beall RC, Shah AA, Dark C. Health policy considerations in treating mental and behavioral health emergencies in the United States. Emerg Med Clin North Am. 2015;33(4):875–91. Scholar
  14. 14.
    Bohn MJ, Babor TF, Kranzler HR. The alcohol use disorders identification test (AUDIT): validation of a screening instrument for use in medical settings. J Stud Alcohol Drugs. 1995;56(4):423–32.CrossRefGoogle Scholar
  15. 15.
    Carey KB, Carey MP, Chandra PS. Psychometric evaluation of the alcohol use disorders identification test and short drug abuse screening test with psychiatric patients in India. J Clin Psychiatry. 2003;64(7):767–74.CrossRefGoogle Scholar
  16. 16.
    Titscher S, Wodak R, Meyer M, Vetter E. Methods of text and discourse analysis. London: Sage Publications; 2000.Google Scholar
  17. 17.
    McCusker J, Karp I, Cardin S, Durand P, Morin J. Determinants of emergency department visits by older adults: a systematic review. Acad Emerg Med. 2003;10(12):1362–70.CrossRefGoogle Scholar
  18. 18.
    Wise-Harris D, Pauly D, Kahan D. Tan de Bibiana J, Hwang SW, Stergiopoulos V. "Hospital was the only option": experiences of frequent emergency department users in mental health. Admin Pol Ment Health. 2017;44(3):405–12. Scholar
  19. 19.
    Olsson M, Hansagi H. Repeated use of the emergency department: qualitative study of the patient's perspective. Emerg Med J. 2001;18(6):430–4.CrossRefGoogle Scholar
  20. 20.
    Carleton RN, Duranceau S, Freeston MH, Boelen PA, McCabe RE, Antony MM. "But it might be a heart attack": intolerance of uncertainty and panic disorder symptoms. J Anxiety Disord. 2014;28(5):463–70. Scholar
  21. 21.
    Bailey KP. Physical symptoms comorbid with depression and the new antidepressant duloxetine. J Psychosoc Nurs Ment Health Serv. 2003;41(12):13–8.PubMedGoogle Scholar
  22. 22.
    Hughes JA, Sheehan M, Evans J. Treatment and outcomes of patients presenting to an adult emergency department involuntarily with substance misuse. Int J Ment Health Nurs. 2018;27(2):593–9. Scholar
  23. 23.
    Olfson M, Mechanic D, Hansell S, Boyer CA, Walkup J, Weiden PJ. Predicting medication noncompliance after hospital discharge among patients with schizophrenia. Psychiatr Serv. 2000;51(2):216–22. Scholar
  24. 24.
    Chaput Y, Lebel MJ, Labonte E, Beaulieu L, Paradis M. Pathological gambling and the psychiatric emergency service. Can J Psychiatr. 2007;52(8):535–8. Scholar
  25. 25.
    Knapp M, King D, Pugner K, Lapuerta P. Non-adherence to antipsychotic medication regimens: associations with resource use and costs. Br J Psychiatry. 2004;184:509–16.CrossRefGoogle Scholar
  26. 26.
    Commissaire à la santé et au bien-être (CSBE). Utilisation des urgences en santé mentale et en santé physique au Québec. Québec Commissaire à la santé et au bien-être; 2017.Google Scholar
  27. 27.
    Da Cruz D, Pearson A, Saini P, Miles C, While D, Swinson N, et al. Emergency department contact prior to suicide in mental health patients. Emerg Med J. 2011;28(6):467–71. Scholar
  28. 28.
    Vandyk AD, Harrison MB, VanDenKerkhof EG, Graham ID, Ross-White A. Frequent emergency department use by individuals seeking mental healthcare: a systematic search and review. Arch Psychiatr Nurs. 2013;27(4):171–8. Scholar
  29. 29.
    Hansagi H, Olsson M, Sjöberg S, Tomson Y, Göransson S. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med. 2001;37(6):561–7. Scholar
  30. 30.
    Williams RI, Volberg RQ, Stevens RMG. The Population Prevalence of Problem Gambling: Methodological Influences, Standardized Rates, Jurisdictional Differences, and Worldwide Trends. Report prepared for the Ontario Problem Gambling Research Centre and the Ontario Ministry of Health and Long Term Care; 2012.Google Scholar
  31. 31.
    Vu F, Daeppen JB, Hugli O, Iglesias K, Stucki S, Paroz S, et al. Screening of mental health and substance users in frequent users of a general Swiss emergency department. BMC Emerg Med. 2015;15:27. Scholar
  32. 32.
    Giguere CE, Potvin S, Signature C. The drug abuse screening test preserves its excellent psychometric properties in psychiatric patients evaluated in an emergency setting. Addict Behav. 2017;64:165–70. Scholar
  33. 33.
    Musgrave C, Timms A, Georgiou G, Glover S, Sque M, Black D, et al. Alcohol-related harm: developing a drug and alcohol liaison team. Br J Nurs. 2018;27(15):881–5. doi: CrossRefGoogle Scholar
  34. 34.
    O'Brien A, Leonard L, Deering D. Could an advance practice nurse improve detection of alcohol misuse in the emergency department? Int J Ment Health Nurs. 2012;21(4):340–8. Scholar
  35. 35.
    Chaput YJA, Lebel M-J. Demographic and clinical profiles of patients who make multiple visits to psychiatric emergency services. Psychiatr Serv. 2007;58(3):335–41. Scholar
  36. 36.
    Chang G, Weiss AP, Orav EJ, Rauch SL. Predictors of frequent emergency department use among patients with psychiatric illness. Gen Hosp Psychiatry. 2014;36(6):716–20. Scholar
  37. 37.
    Beck A, Sanchez-Walker E, Evans LJ, Harris V, Pegler R, Cross S. Characteristics of people who rapidly and frequently reattend the emergency department for mental health needs. Eur J Emerg Med. 2016;23(5):351–5. Scholar
  38. 38.
    Prins M, Meadows G, Bobevski I, Graham A, Verhaak P. Van derMeer K, et al. Perceived need for mental health care and barriers to care in the Netherlands and Australia. Soc Psychiatry Psychiatr Epidemiol. 2011;46(10):1033–44. Scholar
  39. 39.
    Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289(23):3095–105.CrossRefGoogle Scholar
  40. 40.
    Wang PS, Berglund P, Olfson M, Pincus HA, Wells KB, Kessler RC. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):603–13. Scholar
  41. 41.
    Vasiliadis H-M, Lesage A, Adair C, Boyer R. Service use for mental health reasons: Cross-provincial differences in rates, determinants, and equity of access. Can J Psychiatr. 2005;50(10):614–9.CrossRefGoogle Scholar
  42. 42.
    Institut de la statistique du Québec (ISQ). Portrait des statistiques de la santé mentale des québécois. Résultats de l'Enquête sur la santé dans les collectivités canadiennes Santé mentale 2012; Portrait chiffré. Québec: Gouvernement du Québec, Institut de la statistique du Québec; 2015.Google Scholar
  43. 43.
    Kahan D, Leszcz M, O'Campo P, Hwang SW, Wasylenki DA, Kurdyak P, et al. Integrating care for frequent users of emergency departments: implementation evaluation of a brief multi-organizational intensive case management intervention. BMC Health Serv Res. 2016;16:156. Scholar
  44. 44.
    Nesper AC, Morris BA, Scher LM, Holmes JF. Effect of Decreasing County mental health services on the emergency department. Ann Emerg Med. 2016;67(4):525–30. Scholar
  45. 45.
    Fortin M, Bamvita JM, Fleury MJ. Patient satisfaction with mental health services based on Andersen's behavioral model. Can J Psychiatr. 2018;63(2):103–14. Scholar
  46. 46.
    Krupchanka D, Khalifeh H, Abdulmalik J, Ardila-Gomez S, Armiya'u AY, Banjac V, et al. Satisfaction with psychiatric in-patient care as rated by patients at discharge from hospitals in 11 countries. Soc Psychiatry Psychiatr Epidemiol. 2017;52(8):989–1003. Scholar
  47. 47.
    Ruud T, Aarre TF, Boeskov B, le Husevag PS, Klepp R, Kristiansen SA, et al. Satisfaction with primary care and mental health care among individuals with severe mental illness in a rural area: a seven-year follow-up study of a clinical cohort. Int J Ment Health Syst. 2016;10:33. Scholar
  48. 48.
    Poremski D, Harris DW, Kahan D, Pauly D, Leszcz M, O'Campo P, et al. Improving continuity of care for frequent users of emergency departments: service user and provider perspectives. Gen Hosp Psychiatry. 2016;40:55–9. Scholar
  49. 49.
    Padgett DK, Brodsky B. Psychosocial factors influencing non-urgent use of the emergency room: a review of the literature and recommendations for research and improved service delivery. Soc Sci Med. 1992;35(9):1189–97.CrossRefGoogle Scholar
  50. 50.
    Zeman L, Arfken CL. Decreasing unnecessary care in a psychiatric emergency service. Psychiatr Serv. 2006;57(1):137–8. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of PsychiatryMcGill UniversityQuebecCanada
  2. 2.Douglas Mental Health University Institute Research CentreQuebecCanada
  3. 3.Douglas Hospital Research CentreQuebecCanada
  4. 4.Department of Health Administration, Policy and Evaluation, School of Public HealthUniversity of MontrealQuebecCanada
  5. 5.School of Social Work, Addiction Rehabilitation Center, National Capital University Integrated Health and Social Services CenterLaval UniversityQuebecCanada

Personalised recommendations