Photo Credit: iStock.com/CasarsaGuru

Mental health and SUD bias impact the quality of ED care that patients with these conditions receive for physical health concerns, according to research.

Patients with documented mental illness or substance use disorders (SUDs) continue to encounter a mixed—sometimes starkly divergent—quality of emergency department (ED) care when they present with chest pain, abdominal pain, or other non‑psychiatric complaints, according to a patient‑interview study published in Health Services Research.

“Patients with mental health and/or SUDs disproportionately seek medical care in EDs, yet research rarely examines first-hand accounts of their experiences,” wrote study corresponding author Linda M. Isbell, PhD, of the University of Massachusetts Amherst, and colleagues. “This study uncovered negative and positive provider, treatment, and system-related factors that contribute to these patients’ experiences and offered recommendations for improving care experiences.”

Interviewing Patients

Between February 2018 and January 2019, the research team conducted semi-structured bedside interviews with 50 adult patients with electronic health record (EHR)-documented mental health and/or SUD(s) who sought care for a physical health concern during an ED visit to an academic medical center in the Northeastern US, followed by longer follow‑up telephone interviews. Most participants were White (80 %), female (72 %), and living with either a mood disorder, anxiety disorder, or an opioid‑use disorder. The study team employed constant comparative analysis throughout the interviewing, coding, and analysis.

What the Patients Said

According to the study, three key themes emerged:

• Negative encounters dominated. Many respondents described an abrupt shift in clinician demeanor—“dismissive,” “rushed,” or “unprofessional”—once their mental‑health history surfaced. Several reported having legitimate pain attributed to anxiety or withdrawal, a classic case of diagnostic overshadowing.
• Positive stories existed. A minority praised clinicians for being “attentive,” “communicative,” and “efficient,” underscoring that high‑quality care is achievable, even in a crowded ED, according to the authors.
• Systemic strain was obvious. Patients sensed that overcrowding and limited behavioral resources compelled staff to engage in transactional interactions, which often left expectations unmet.

Why It Matters

The authors listed possible repercussions of negative patient experiences detailed in the study, including:

• Diagnostic overshadowing = missed pathology. Assuming that chest discomfort is “just anxiety” in a patient with a panic disorder can delay acute coronary syndrome work‑ups.
• Hospital Consumer Assessment of Healthcare Providers, Systems, and Patient‑Experience scores—and word of mouth—suffer when bias is perceived, jeopardizing both reimbursement and community trust.
• Safety net at capacity. Behavioral health boarding and ED overcrowding erode morale and increase the risk for errors for every patient.

Action Steps

Key recommendations from the study team included:

• Build anti‑stigma reflexes. Integrate brief, case-based bias modules into annual competency training.
• Screen pain objectively. Use validated scales and document rationale whenever withholding opioids or delaying imaging.
• Co‑locate behavioral teams. Embedding a psychiatric registered nurse or SUD counselor can decompress boarding and free physicians to manage medical presentations.
• Clarify ED scope. Provide printed “What to Expect” one‑pagers at registration to align patient expectations with ED capabilities.

Reform: Needed & Possible

The authors noted that while bias against mental health and SUD histories still shapes some emergency encounters, targeted education, objective protocols, and integrated behavioral services can narrow the gap between expected and delivered care, improving outcomes for a vulnerable, high‑utilization population.

“Reform to our health care system is urgently needed to ensure quality care for all—particularly our most vulnerable members of society,” the authors concluded.