Experiences providing care to patients with mental health conditions in a tertiary care hospital emergency department in Jerusalem.

ED staff exhibited a high level of stigma towards patients with mental illness.

• Based on inductive thematic analysis of 24 semi-structured interviews with staff members at a tertiary-care hospital ED in Jerusalem.
• Many providers were aware that negative perceptions of these patients were potentially harmful.
• Staff stigma was identified as a pervasive theme across provider experiences.
• In some cases, providers tried to mitigate the effects of stigma on patient care.

Providers recognized that stigma may lead to diagnostic overshadowing of patients with mental health conditions.

• Many providers were explicitly aware that negative perceptions could lead to diagnostic overshadowing.
• Diagnostic overshadowing refers to physical symptoms being attributed to mental illness rather than being investigated on their own merits.
• This awareness was identified through thematic analysis of the 24 semi-structured interviews.
• Awareness of the problem did not always translate into changed behavior among staff.

Staff frequently viewed patients with mental illness as inappropriate users of the ED and assumed limited responsibility for their care.

• This perception of patients as 'inappropriate users' of the ED was a key theme identified in the study.
• Staff assuming limited responsibility for mental health patients was a distinct finding from the thematic analysis.
• This finding was derived from 24 semi-structured interviews conducted at a Jerusalem tertiary-care hospital ED.
• This attitude was identified as potentially harmful to patient outcomes and quality of care.

ED providers reported inadequate training and skills for treating and managing patients with mental health conditions.

• Inadequate training and skills were identified as a distinct theme across the 24 staff interviews.
• Organizational and structural constraints were also identified as compounding challenges for staff.
• The study was conducted in the context of the 2023 Israeli war, which has substantially increased mental health-related ED visits.
• These deficits were identified alongside stigma as major barriers to adequate mental health care in the ED.

The study recommends multiple interventions to improve mental health care in EDs, including educational workshops, mental health specialist support, calm environments, expert-by-experience collaboration, and person-centered risk assessments.

• Recommendations include educational workshops for ED staff to address stigma and improve skills.
• Greater involvement of mental health specialists within EDs was recommended.
• Providing calm environments for patients with mental health conditions was identified as an important structural change.
• Working alongside 'experts by experience' (people with lived experience of mental illness) and conducting person-centered risk assessments were also recommended.
• Strengthening collaboration and referral pathways to community-based mental health services and providing alternative care such as community crisis centers were highlighted.

The war that started in Israel in 2023 has had substantial adverse effects on population mental health, increasing demand for emergency mental health services.

• Mental health-related visits to the ED tend to increase during and after public health crises.
• The 2023 war in Israel was identified as a specific contextual factor driving increased mental health ED utilization.
• The study was conducted at a tertiary-care hospital ED in Jerusalem.
• The findings are described as relevant to mitigating 'the expected post-war mental health crisis in Israeli EDs' and are noted as relevant to many other countries.