Crisis

Psychiatric Consultation and Referral of Persons Who

Have Attempted Suicide: The Perspective of Heads of
Emergency and Psychiatry Departments
Marc Roelands, Reginald Deschepper, and Johan Bilsen
Online First Publication, February 23, 2017. http://dx.doi.org/10.1027/0227-5910/a000445

CITATION
Roelands, M., Deschepper, R., & Bilsen, J. (2017, February 23). Psychiatric Consultation and
Referral of Persons Who Have Attempted Suicide: The Perspective of Heads of Emergency and
Psychiatry Departments. Crisis. Advance online publication. http://dx.doi.org/10.1027/0227-
5910/a000445
Clinical Insights

Psychiatric Consultation and

Referral of Persons Who Have
Attempted Suicide
The Perspective of Heads of Emergency and Psychiatry
Departments
Marc Roelands, Reginald Deschepper, and Johan Bilsen

Mental Health and Wellbeing Research Group, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Belgium

Abstract. Background: Persons who have attempted suicide are often admitted to a hospital’s emergency department (ED). The risk of them
repeating their attempt is lower if they have had access to a psychiatrist in hospital and had been referred to mental health care services.
However, the literature suggests this is often lacking. Aims: To describe perceived barriers to and supportive factors for psychiatric consultation
and appropriate referral of suicide attempters in the ED. Method: The perspective of the heads of emergency and psychiatry departments in all
hospitals with an ED in Brussels-Capital Region was investigated with a qualitative study. Data were obtained with semistructured personal
interviews and analyzed in the tradition of content analysis. Results: Eight emergency physicians and 11 psychiatrists participated. Perceived
barriers can be summarized as a lack of resources in the ED in terms of psychiatrists, psychiatric beds, and a room for counseling. Intense
collaboration between physicians and psychiatrists and integration in a network of mental health services were perceived as being supportive
factors. Conclusion: According to the heads of department, psychiatric consultation and referral of suicide attempters could be improved by
an increase and more even distribution of beds for temporary psychiatric hospitalization in the ED and a more appropriate financing of the
psychiatry function in the ED.

Keywords: suicide, emergency, psychiatry, communication, quality of care

A previous suicide attempt is the most important risk factor
for suicide (Cavanagh, Carson, Sharpe, & Lawrie, 2003)
and people who are admitted to a general hospital for
self-harm are at an increased risk of a suicide attempt and
suicide (Beautrais, 2003; Crandall, Fullerton-Gleason,
Aguero, & LaValley, 2006; Gairin, House, & Owens,
2003; Hawton, Zahl, Weatherall, 2003; Owens, Horrocks,
& House, 2002). Therefore, the emergency department
(ED) of a hospital is a good opportunity for suicide pre-
vention as people who have attempted suicide (further:
suicide attempters) are often referred to it (Larkin & Beau-
trais, 2010). The rate of suicidal behavior among general
practice patients is declining in Belgium (Boffin, Bossuyt,
Vanthomme, & Van Casteren, 2011). Repeated attempts
are lower in patients who have had an appointment with a
psychiatrist in hospital (Hickey, Hawton, Fagg, & Weitzel,
2001), who are referred to specialized mental health care
services after hospitalization (Fleischmann et al., 2008;
Guthrie et al., 2001; Kapur et al., 2004; Morgan, Jones,
& Owen, 1993), or who receive psychological or psycho-
social interventions after an attempt (Brown et al., 2005;
Hawton et al., 1998; Henggeler et al. 2004; Hepp, Witt-
mann, Schnyder, & Michel, 2004). However, one study
found that the majority of patients admitted to an ED left
the hospital without any psychiatric consultation (Hickey
et al., 2001). These findings prompted the World Health
Organization (WHO) to recommend (a) comprehensively
assessing everyone presenting with acts of self-harm/sui-
cide and (b) education and training of emergency care staff
(WHO, 2014).
However, it is not clear whether these recommendations
are put into practice and which factors have an impact on
their implementation. We studied the subject by investi-
gating the views of the heads of the emergency and psy-
chiatric departments, as we assume that they are aware of
the reality of daily clinical work as well as having an overall
view of the organization of care.
This study aims to describe the perspectives of the heads
of the emergency and psychiatry departments in hospitals
on conditions that support and block psychiatric consulta-
tion and the appropriate referral of persons who are admit-
ted to the ED after a suicide attempt.

© 2017 Hogrefe Publishing Crisis 2017

DOI: 10.1027/0227-5910/a000445
2 M. Roelands et al.: Psychiatric Consultation and Referral at the Emergency Department

Method Data Analysis

Study Design, Population, and Sample The aim of the study was to arrive at a qualitative descrip-
tion of experts’ opinions on perceived barriers and sup-
portive conditions. To remain as close as possible to the
The explorative nature of the study demanded a qualita-
lived experience of these heads of departments, there was
tive study design focusing on expert opinions. All heads of
no underlying, predetermined theoretical framework (e.g.,
emergency and psychiatry departments (including child
on service use) behind the questions. Data were analyzed
psychiatry departments if existing) who worked in one of
in the tradition of content analysis (Neuendorf, 2002; Va-
the 11 hospitals in Brussels-Capital Region that had an ED
ismoradi, Turunen, & Bondas, 2013) to represent the ex-
were contacted for participation in the study (total popu-
perts’ responses directly (Crowe, Inder, & Porter, 2015).
lation sample). They were informed about the study with
We developed a manual data management system and
a letter and afterward contacted by telephone to obtain
procedure adapted to the nature of the data and the sample
their consent and make an appointment. Brussels-Capital
(expert opinions).
Region is an urban administrative area of about 1.1 mil-
To prepare the analysis, interview notes taken during
lion inhabitants. We selected it as study the area because
the interview were transcribed into one text document
of (a) its high density of a wide range of mental health care
per interviewee. Additionally, they were entered in one of
services, and (b) the heterogeneity of its population (Ob-
three text matrixes, one for each professional category, to
servatorium voor Gezondheid en Welzijn Brussel, 2006).
support a more structured comparison of responses from
This complexity optimized the odds of understanding the
different persons on the same topic. The recorded inter-
factors involved.
views were not transcribed, as this is a time-consuming
undertaking that we believe is less necessary in the case of
semistructured interviews.
Data Collection
The data, consisting of the interviewer’s notes, text ma-
trixes, and audio files, were analyzed in five steps. Firstly,
Data were obtained by means of a semistructured, person-
all notes were collected in one Word file and subsequently
al interview at the interviewee’s office in the language they
summarized by topic, always differentiating between psy-
preferred, being French or Dutch. An interview schedule
chiatrists and physicians. The interviewee’s initials were
was designed by the first author to maximize the response
added to each text fragment, so that their statements could
from this limited group of heads of departments, who have
be understood in the context of their other statements and
busy timetables. Its general structure and wording were
the characteristics of their specific hospital or department.
refined through a discussion with an emergency physician
Secondly, these summaries of statements on each top-
(further: physician) and a psychiatrist. It was loosely used
ic were compared with the text in the matrixes, and the
during the interview to elicit responses, which was ex-
summaries of statements were refined as needed. Thirdly,
plained to the interviewee. The interview consisted of four
these statements were further summarized, including nu-
main topics: the actual procedure of taking care and refer-
ances where necessary. Fourthly, all audio tapes available
ral, barriers to the quality of care, barriers to the quality of
were listened to, to check whether any important informa-
referral, and conditions supporting quality of care. After
tion had been left out or statements misunderstood. Final-
these topics had been discussed extensively, some gener-
ly, the resulting text was transferred to the interviewees for
al topics were touched upon: how the service copes with
feedback, so that they could suggest nuances that were tak-
language differences as a potential barrier and ideas about
en into consideration, to improve consensus between the
the preferred and ongoing changes in the organization of
interviewer and interviewee, and to confirm the former’s
the care of suicide attempters at the EDs in Brussels. The
description. Verbatim extracts from the transcripts are not
schedule was constructed as a funnel first eliciting general
presented here owing to space limitations.
views and then more specific concerns (Smith & Osborn,
2008). When it was felt to be necessary, the interviewer
probed further with additional questions. The first author,
an experienced interviewer, interviewed all the partici-
Ethical Considerations
pants. Interviews typically lasted 45 min (range: 30–90
The study protocol was approved by the combined Medi-
min) and were audio-recorded if the interviewee agreed.
cal Ethical Committee of the academic hospital “Universi-
The interviewer took notes during all interviews.
tair Ziekenhuis Brussel” and the Vrije Universiteit Brussel
(VUB).

Crisis 2017 © 2017 Hogrefe Publishing

M. Roelands et al.: Psychiatric Consultation and Referral at the Emergency Department
Results
Sample
Eight heads of an ED (including one acting head), affiliated
to seven hospitals, and 11 heads of a psychiatry department
(of whom three from a child psychiatry department), affiliat-
ed to 10 hospitals, participated. Together they represented
ten hospitals. There was one hospital at which no one partici-
pated. Three psychiatrists and one physician declined to par-
ticipate; three physicians could not be contacted personally
by telephone to obtain consent and to make an appointment.
Stages of Care
We were able to distinguish the following successive stages
in taking care of suicide attempters:
1. Triage by a nurse according to the urgency of the phys-
ical problems;
2. Diagnosis of physical problems and presence of suicide
intention by physicians at the ED;
3. Treatment of physical problems at the ED or other de-
partments of the hospital by physicians and nurses ac-
cording to needs;
4. Appointment with a psychiatrist, including assessment
of the suicide risk; and
5. Referral of the suicide attempter by a psychiatrist to
mental health care services.
Stages 1–4 are referred to as consultation, Stage 5 is dis-
cussed as referral. As will be seen here, barriers especially
arise at Stages 4 and 5.
Barriers to Consultation
All the results are summarized in Table 1. In general, the
medical treatment of suicide attempters was perceived by
physicians as being optimal and often simple, so in this re-
gard they did not experience problems. Moreover, psychia-
trists stated that in general, psychiatric consultation for sui-
cide attempters was run well. Physicians and psychiatrists in
academic hospitals presented the areas of possible improve-
ment as minor ones. According to a physician in an academ-
ic hospital that does not have huge problems, his staff should
take care that physical assessment is always completed be-
fore referring suicide attempters to the psychiatrist. Large
departments pointed out the need for clear communication
between physicians and psychiatrists. Psychiatrists in ac-
ademic hospitals went so far to state that the situation did
not need to change because everything was fine. They only
suspected that in some cases they were not consulted by the
© 2017 Hogrefe Publishing
3
physicians, although this would have been advisable. How-
ever, in hospitals with fewer resources, barriers to consulta-
tion with a possible profound impact were mentioned.
Physicians were univocally clear that suicide attempters
require substantially more time and resources from the ED.
Those physicians who thought that their department was
sufficiently staffed defended the use of emergency care in
all cases by pointing to its function as the real “first line of
care.” However, physicians who thought their service was
understaffed preferred that persons who had attempted su-
icide or had another problem who did not require emergency
care to go to the general practitioner. They perceived admit-
tance to the ED as being due to a lack of knowledge or incor-
rect information about the system, the fact that payment is
not required upon leaving the ED (it is required at the GP’s
surgery), that no appointment is needed, and that the seri-
ousness of the problem was wrongly estimated. These physi-
cians felt that this behavior hampers psychiatric consultation
for suicide attempters when necessary, due to an overload on
beds and staff time, including psychiatrists’ time.
In academic hospitals, sufficient psychiatrists were avail-
able and the psychiatry facilities were fairly well integrated
in the ED with specific persons working only or mainly at
the ED and having a separate consultation room. However,
in many nonacademic hospitals, psychiatric consultation
was perceived by physicians as being difficult to organize.
If a psychiatrist is not available around the clock, this was
perceived by most physicians as a problem as it increases
the time of stay in the ED. Moreover, they were aware of
the suicide risk. As such, these physicians perceived a need
for additional psychiatric or psychological expertise in the
emergency room. They even considered nurses or clinical
psychologists if psychiatrists were not available.
In these nonacademic hospitals, psychiatrists felt also a
considerable need for more psychiatrists or psychologists
so that appointments would be available around the clock.
Additionally, they preferred the psychiatric facilities to be
fully integrated in the ED, including a cozy room for coun-
seling. Another consequence was that suicide attempters
were referred by psychiatrists to university hospitals that
could provide the necessary psychiatric support in the
evening and at night.
Many causes given for the unavailability of psychiatrists
in the ED had to do with a limited availability of psychia-
trists in general, and specifically in hospitals. At one small-
er hospital, psychiatric support is not available at all as no
psychiatry department exists. In smaller hospitals with a
psychiatry department, a resident psychiatrist who is inte-
grated into the ED around the clock is not cost- effective,
as the incidence of admissions for attempted suicide is
low. Most important is the limited number of psychia-
trists available to hospitals in Belgium, whether resident
psychiatrists or consultants. Indeed, the former take on a
Crisis 2017
4 M. Roelands et al.: Psychiatric Consultation and Referral at the Emergency Department

Table 1. Opinions of heads of emergency departments (EDs) and psychiatric departments about barriers and supportive factors to psychiatric
consultation and appropriate referral of suicide attempters at the EDs of hospitals in Brussels-Capital Region, 2015

Themes Emergency physician Psychiatrist

Barriers to consultation
Unnecessary use of ED
Unavailable psychiatrist at ED
Beds for observation
Expertise of nurses and physicians
Barriers to referral to mental health services
Capacity of intensive mental health care
Procedures of centers for ambulant mental
health care
Availability of crisis units and units for
psychiatric emergency intervention
Access to residential mental health care
Access to general practitioners
Financing of chronic care to illegally staying
persons
Other barriers
Factors that support psychiatric consultation and referral
Availability and effort of staff
Collaboration with external mental health
care services
Continuity of care
Centralization of psychiatric services inte-
grated in ED
Language proficiency
Was perceived as a problem by heads of –
understaffed ED, hampering psychiatric
consultation when needed.
In nonacademic hospitals, unavailability 24/7 In nonacademic hospitals, 24/7 presence and
increases time at ED. fully integration in ED was preferred.
Mostly not available but perceived as an Mostly not available but perceived as an
asset. asset.
– Specific expertise is limited.
– Long waiting lists at psychiatric department
of same hospital and ambulant mental health
care services.
Structural problem of shortage in child
psychiatry.
– Procedures do not fit the needs of suicide
attempters.
– These useful units are rare.
– Long waiting lists prevent their use.
– Their limited accessibility slows referral.
– Financing rules hamper appropriate care.
– Limited availability of psychiatrist, time con-
straints and limited expertise at ED regarding
suicide attempters in smaller hospitals.
Quality of care by staff at ED and good collab- Quality of care by staff at ED, good collabo-
oration with psychiatrists, especially when ration with psychiatrists, availability of beds
integrated in ED. in psychiatric department and outreach
possibilities.
– Being integrated in a network of services.
– Integration of psychiatric function at ED in the
functioning of the psychiatric department.
Sensitive scenario with consequences for Sensitive scenario with consequences for
referral procedures and financial conse- referral procedures and financial conse-
quences for hospitals. quences for hospitals.
All hospitals have organized their own mix of All hospitals have organized their own mix of
solutions. solutions.

substantial proportion of the workload in academic and
nonacademic hospitals and are essential for responding to
care demands. Additionally, to handle this shortage, some
university departments that are all linked to academic hos-
pitals have recently assigned their resident psychiatrists
exclusively to the academic hospitals, increasing the prob-
lem of limited availability at the other hospitals.
Beds for up to 24-hr observation at the ED were often
not available, even in large hospitals, and were perceived by
physicians and psychiatrists as an asset, especially by EDs
that had many suicide attempters. Psychiatrists in some
hospitals mentioned an additional barrier to the quality of
the psychiatric consultation, namely, the lack of rooms for
observation over more than 24 hr. It is not legally possible
to keep people in the ED for a longer time unless a special
license is granted. Psychiatrists working in larger hospitals
in the old city center, whose patients tend to be less affluent
and have a psychiatric pathology colored by social problems

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M. Roelands et al.: Psychiatric Consultation and Referral at the Emergency Department
and ethnic differences, also mentioned the lack of beds for
observation as a barrier to the quality of care.
All psychiatrists agreed that the specific expertise of
nurses and physicians in the ED regarding suicide attempts
is limited.
Barriers to Referral to Mental Health
Services
Referral of suicide attempters to mental health care servic-
es is only done by psychiatrists and was therefore only dis-
cussed with them. In general, they indicated that problems
existed but that they could manage them. After further dis-
cussion, barriers to referral emerged.
Referral of suicide attempters to mental health care ser-
vices was problematic for everybody to a certain degree,
especially short-term mental health treatment, whether
residential or for outpatients. All psychiatrists agreed that
waiting lists at the psychiatric department of the same hos-
pital (e.g., 4 months) and outpatient services for mental
health care were extremely long.
All child psychiatrists, both academic and nonacademic,
experienced the same problems with referral to outpatient
care, psychiatric hospital care, and the psychiatric depart-
ment of their own hospital. They indicated that there is a
structural problem of shortage: There is a need for inten-
sive residential and outpatient mental health care. Only
one psychiatrist did not perceive this referral problem
when children were 15 years or younger, thanks to a privi-
leged relationship with another institute.
Regarding outpatient centers for mental health care,
some hospitals seldom contacted them because their capac-
ity was felt to be too limited, not adapted to the needs of sui-
cide attempters who need instant help, and the decision pro-
cess after intake (regarding motivation for change etc.) was
perceived as taking too long in cases of attempted suicide.
In academic hospitals with a crisis unit, these beds are
used for suicide attempters but have to be available for oth-
er people in crisis, such as drug users, as well. The limited
number of beds in these hospitals leads to difficult care
choices. Moreover, most hospitals are not licensed to have
them. An additional problem is that these beds at the cri-
sis unit are also used for teenagers aged 16–18 who have
attempted suicide, although psychiatrists felt this group
requires specific emergency measures and should not be in
contact with persons with severe mental health disorders.
K-beds, meant for the observation and treatment of chil-
dren and adolescents, have a waiting time of about 1 week.
A Unit for Psychiatric Emergency Intervention where pa-
tients can stay for up to 5 days was perceived as necessary:
Some hospitals have one, but at least one academic hospi-
tal does not, although it is trying to develop one.
© 2017 Hogrefe Publishing
5
In cases of severe psychiatric disorders, sometimes with
a longer history, psychiatric hospital care can be necessary.
The smaller hospitals and one large, city-center hospital,
all nonacademic, stated that waiting lists for this kind of
care are too long. As a consequence, they are not used for
this patient population. Psychiatrists at an academic and a
nonacademic psychiatric department for children confirm
this. The nonexistence of these beds in the wider area is
part of the problem.
Collaboration with the general practitioner of the person
who attempted suicide was felt to be important for contin-
uation of mental health care, but their limited accessibility,
which slows the process, was mentioned by the majority of
psychiatrists as a problem.
Financing of health services in Belgium is based on the
number of citizens and services have been developed ac-
cordingly. However, some estimate that about 2% of cit-
izens are illegal residents and that these individuals are
overrepresented in mental health care (the author suspects
that this is sometimes due to social problems) and espe-
cially overrepresented in inner-city hospitals. Long-term
care cannot be financed for illegal residents. One psychi-
atrist mentioned this as a barrier to appropriate referral to
care for suicide attempters who are not legally resident.
Some internal causes of difficult referrals were only
mentioned by psychiatrists in smaller hospitals, namely,
the lack of psychiatric availability around the clock, time
constraints by psychiatrists, physicians, and nurses, and
limited expertise among physicians and nurses at the ED
regarding suicide attempters.
Factors That Support Psychiatric
Consultation and Referral
Physicians and psychiatrists were asked what they thought
were the most important factors that currently supported
the actual quality of their care and referral.
Regarding the physical care of suicide attempters, physi-
cians mentioned the availability, effort, and quality of their
staff at the ED (a multidisciplinary team consisting at least
of physicians and nurses). They perceived most nurses and
many physicians as being sensitive and empathic toward
suicide attempters. Staff training was perceived as useful
in this regard, when provided.
Regarding their collaboration with psychiatrists, physi-
cians highly valued the psychiatrists’ efforts to make them-
selves available and to take care of suicide attempters.
Where there were clinical psychologists or a psychiatric
service within the ED, their presence was also highly val-
ued. A cozy room for the psychiatrist to meet the suicide
attempters in this emotional situation was felt to be valua-
ble in this respect.
Crisis 2017
6 M. Roelands et al.: Psychiatric Consultation and Referral at the Emergency Department
Psychiatrists also emphasized the value of collabora-
tion. Psychiatric consultation and referral were perceived
to be currently supported by the availability and effort of
competent staff, guaranteeing qualitative assessment of
the patient and follow-up of the patient’s social situation.
Outreach possibilities were appreciated: The presence of a
liaison team visiting suicide attempters in all departments
of the hospital (intensive care, internal medicine, surgery)
and a mobile team visiting patients out of the hospital but
that is based at the hospital with staff who works there was
felt to be supportive in those cases where it was available.
Additionally, the availability of sufficient beds in the psy-
chiatric department of the hospital was felt by some to be
supportive.
Psychiatrists emphasized collaboration and integration
of the department in the regional network of mental health
care, based on clear agreements with mutual benefits. The
availability and competence of specific organizations in
the network of each hospital were emphasized. Each hos-
pital was found to have developed its own network.
In some hospitals and in all three child psychiatry de-
partments, continuity of care was perceived as an impor-
tant factor guaranteeing the quality of care. In other words,
the integration of the psychiatric facilities at the ED into
the functioning of the psychiatric department: Every psy-
chiatrist comes to the ED, in the psychiatric department,
offers appointments, and takes part in liaison psychiatry.
The question of whether quality of care could be im-
proved by the centralization of psychiatry integrated into
the ED at a small number of hospitals (two or three) was
received with mixed feelings. Some physicians and psy-
chiatrists remarked that in this system, referrals by ambu-
lances to hospitals should be of high quality, needing the
expertise of a physician and a nurse, who are currently not
involved. Alternatively, suicide attempters could also re-
ceive somatic care at the nearest hospital and afterward be
referred to a centralized service for mental health evalua-
tion and referral. An important factor to take into consider-
ation in this discussion, which was also presented by some
physicians and psychiatrists, is that the ED is a door to all
hospital departments and as such interventions in the care
pathway of suicide attempters have financial consequenc-
es for the hospitals.
In the hospitals of this multicultural capital city, lan-
guage differences seem not to hinder consultation and re-
ferral, according to the heads of these departments. Nearly
all hospitals, whether smaller or academic, have organized
their own mixture of solutions to support quality of care,
that is, staff in ED and psychiatrists who are bi- or trilin-
gual, a list of all the staff in the entire hospital with specific
language proficiencies, and, to a lesser degree, profession-
al interpreter services.
Crisis 2017
Discussion
To summarize, emergency physicians and psychiatrists
agreed to a considerable extent when describing the per-
ceived barriers and supportive factors for psychiatric
consultation and the referral to mental health services of
suicide attempters in Brussels hospitals. The common de-
nominator was a need for more resources at the ED in terms
of psychiatrists or clinical psychologists, psychiatric beds
for intensive psychiatric care, and a room for counseling.
Factors they perceived as being the most supportive of psy-
chiatric consultation and referral in their own hospital were
the availability of a psychiatric service within the ED, the
integration of the department into the regional network of
mental health care services, continuity of care, and a mix-
ture of solutions to cope with language differences.
The study has some characteristics that could be seen
as limitations. The study area is only one small area in Eu-
rope. However, by describing the emerging problems in
hospitals that differ quite strongly, in a city in the center
of Europe with a heterogeneous population, this study has
the potential to provide insights into the actual care pro-
cess for suicide attempters at EDs that are relevant for pol-
icy makers at different levels (national, regional, hospital)
and researchers in other places.
One could raise the observation that cultural factors in
consultation and referral (such as the perception of men-
tal illness and a taboo on suicide) were not mentioned as
limitations by the heads of departments. However, it prob-
ably means that they are felt as being less crucial to the
problem. A separate study could focus specifically on the
involvement and level of impact of cultural factors, espe-
cially in light of recent migration flows.
Owing to time constraints, peer checking of intercoder
reliability was not feasible. Although often used, this prac-
tice has encountered skepticism (Joffe & Yardley, 2004).
We agree with Krippendorff (2004) that one of the best
ways to judge the quality of the findings is whether new in-
sights into the studied phenomenon have been provided,
which is the case in this study.
The main strength of the study is that it is the first in-
vestigating the care of suicide attempters at the ED in a
broad, qualitative manner, and more specifically from the
perspective of the heads of department themselves.
An additional strength is our data collection procedure:
a two-phase contact to motivate participation (letter and
subsequent telephone contact), followed by a personal
interview in the language chosen by the interviewee. It
aimed for a total population sample in a well-defined area,
avoiding selection bias as much as possible.
All heads of departments perceived intense collabo-
ration between physicians in the ED and psychiatrists as
being a supportive factor of quality of care, and strongly
© 2017 Hogrefe Publishing
M. Roelands et al.: Psychiatric Consultation and Referral at the Emergency Department
emphasized the persistent shortage of psychiatrists. This
perceived shortage of psychiatrists in general has been dis-
cussed for many decades (Knesper, 1980). Regarding the
lack of sufficient presence and integration of psychiatrists in
the ED, four groups of hospitals seem to exist in Brussels.
Academic hospitals with direct access to resident psychia-
trists could develop a psychiatric service fully integrated
into the ED. They attracted many suicide attempters, di-
rectly or through reference from other EDs, and perceived
that they managed to take care of this population. A non-
academic hospital that has access to resident psychiatrists,
combined with a continuity of care model, was also felt to be
adequate. Nonacademic hospitals in affluent environments
were approached much less by suicide attempters, accord-
ing to the psychiatrists, and combined with a continuity
of care model, the psychiatric facilities could be provided
adequately, even without resident psychiatrists. However,
in academic hospitals with no direct access to residents,
situated in less affluent environments (inner city), demand
from suicide attempters was considerable as the incidence
of suicide attempts was higher among homeless, poor, and
substance-using persons, as expected (Dupéré, Leventhal,
& Lacourse, 2009; Eynan et al., 2002; Nordt, Warnke, Sei-
fritz, & Kawohl, 2015). Moreover, resources in these depart-
ments were limited. Providing psychiatric facilities around
the clock at these EDs was necessary, but financial barriers
prevented it. A promising solution that is currently being
tested was the addition of clinical psychologists, who are
sufficiently available on the labor market.
A consensus seemed to exist that more beds are need-
ed in the ED for temporary psychiatric hospitalization,
which will solve many referral difficulties. In this setting,
therapists will work intensely with the patient in crisis for a
maximum of 5 days. This setting is thought to have a better
outcome than current alternative solutions. Indeed, short-
stay units have been found to be useful alternatives to hos-
pitalization when treating psychiatric patients in emergen-
cy situations (Mok & Watler, 1995; Yohanna et al., 1998).
Therefore, some hospitals are currently jointly trying to get
this concept funded. More beds in the psychiatric depart-
ments of hospitals or in long-term care will not solve the
problem as it is perceived that these services will be satu-
rated again in a very short time.
To cope with language differences, all hospitals had im-
plemented an almost identical mixture of solutions. Apart
from this, we assume that self-selection by patients also
exists at some smaller hospitals, with the result that lan-
guage limitations are felt less.
We understand some barriers to good referrals that were
only found in smaller hospitals are due to their small scale,
combining limited available staff and limited experience
with suicide attempters. Consequently, they had difficul-
ties with people who attempted suicide. Further research is
© 2017 Hogrefe Publishing
7
needed regarding the feasibility and appropriateness of the
scenario where the emergency care of mental health con-
ditions is centralized at a small number of psychiatry ser-
vices that are fully integrated into emergency services sit-
uated in academic hospitals. A centralized scenario would
probably facilitate the implementation of a care pathway
in what can currently be described as a heterogeneous en-
vironment. To our knowledge no experiences have been
published regarding the development or implementation
of a care pathway for psychiatric emergency cases.
Conclusion
To our knowledge, this is the first study to investigate the
process of care at the ED of persons who are admitted af-
ter a suicide attempt. According to heads of emergency and
psychiatry departments in Brussels, the main measures
that would improve the quality of psychiatric care and the
referral of suicide attempters are an increase in and more
even distribution of beds for temporary psychiatric hospi-
talization in the ED, and a more appropriate financing of
the psychiatry/psychology facilities at the ED. At present,
the continuity of care model at a larger number of dis-
persed hospitals and a centralization of psychiatry in a few
well-staffed, highly developed academic hospitals coexist
as solutions for these perceived barriers to psychiatric care
and referral of suicide attempters. However, the uneven
distribution of resources requires further attention to guar-
antee an even distribution of high-quality care. The effects
and implementation of the further centralization of psychi-
atric consultation and referral of people who have attempt-
ed suicide should be studied at a limited number of EDs.
Acknowledgments
The study was commissioned and financed by Innoviris,
the Brussels Institute for Research and Innovation (Grant
2015-PRFB-226).
The principal researcher has a master and doctoral edu-
cation in psychology with experience in both quantitative
and qualitative research. One of the co-authors is a profes-
sor in qualitative research methodology. Both co-authors
also have another background. We have tried to present
the views of the interviewees as precisely as possible and
avoided including personal opinions or interpretations.
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Received February 2, 2016
Revision received September 21, 2016
Accepted October 4, 2016
Published online February 23, 2017
About the authors
Marc Roelands, PhD, is a clinical psychologist and senior researcher
who has been affiliated to different research institutes, mainly working
from a public mental health perspective. Research domains include
formal and informal care, suicide, epidemiology of dementia and de-
pression in the elderly, and illicit drug use. He has extensive experience
in survey research.
Reginald Deschepper, PhD, is a medical anthropologist and professor,
specialized in qualitative research. He supervises junior researchers
obtaining a PhD and teaches in the Faculty of Medicine, Vrije Univer-
siteit Brussel, Belgium.
Johan Bilsen, PhD, is a social health scientist and professor. He is Head
of the Mental Health and Wellbeing Research Group, Vrije Universiteit
Brussel, Belgium, and Vice-Head of the Department of Public Health.
He supervises junior researchers obtaining a PhD and teaches various
courses to medicine and health management students.
Marc Roelands
Laarbeeklaan 103 (blok K)
1090 Brussel
Belgium
marc.roelands@vub.ac.be
© 2017 Hogrefe Publishing