Introduction

Assessing and managing patients with mental health problems or substance misuse problems in the emergency department (ED) is one of the most crucial and challenging aspects of psychiatric practice in general hospitals. However, it has long been an unpopular, neglected, risky and rather controversial task. It remains unpopular with patients, mental health professionals and ED staff alike, though each group has its own distinct issues. Patients complain of an unsuitable physical environment, lack of privacy, long delays before being seen and inappropriate decision-making. Consultant psychiatrists have understandably shied away from taking responsibility for numerous high-risk decisions made under pressure of time by a large number of different trainee psychiatrists at all hours of the day and night. Academic psychiatrists have, with a few notable exceptions, avoided the ED as a research area so there is not yet much evidence to guide practice. Emergency department staff may see patients with mental health and substance misuse problems as a numerically small, but potentially high-risk, group and quietly resent being the unacknowledged out-of-hours support to local community mental health services.

Before the situation can be improved nationally one question has to be settled. Is mental health work in the ED simply emergency community psychiatry being practised in the wrong setting because of a lack of planning and resources (Harrison & Bruce-Jones 2003), or is it an example of a specialist liaison psychiatry service to a single department of the general hospital (Cassar et al. 2002; Henderson et al. 2003)?