Police and clinician diversion of people in mental health crisis from the Emergency Department: a trend analysis and cross comparison study

Over an eight-month period (2009–10), Victoria Police was directly involved in the
mandatory transportation of 2401 people in some form of mental health crisis 13]. The clear majority of these people were transported directly to EDs. Given the strong
indication of the negative experience of people in mental health crisis processed
through EDs 5], 8], 17], alternative management pathways are required.

The major finding of this study was the ability of a combined police and mental health
clinician second responder team to prevent the mandatory transportation of people
in mental health crisis to the ED (see Figs. 2 and 3). This diversion was primarily to the least restrictive alternative environment,
which involved assessment in the community and subsequent referral to a variety of
community mental health and social care agencies (including community mental health
centres, alcohol and other drug services, general practitioners, and accommodation
options). Furthermore, a combined police and mental health clinician response better
facilitated direct access to mental health inpatient services for those in mental
health crisis, compared with direct access with a stand-alone police response in the
state of Victoria 13].

The high rate of ED diversion to the community at initial contact in the current study
contrasts to earlier findings where a second responder team resulted in 19 % of people
in crisis remaining in the community at the point of initial assessment 14]. This disparity may be attributable to several factors, primary of which may be the
substantial time difference between the two studies, locations (metropolitan Melbourne
and Los Angeles) and the high rate of past criminal involvement of the cohort in the
Lamb et al. 14] study.

Despite these benefits, a minority of people in mental health crisis in the current
study were transported to a police station for assessment (see Fig. 3). Presumably, transportation to the police station was for safety reasons initiated
by the front line first responder police. A further presumption is that this experience
was transitory as most people were transferred to acute inpatient service or returned
to their communities following assessment by NPACER. However, this study tells us
little about the experience of people transported to police stations or the appropriateness
of this diversion. Such diversion should be averted given the potential criminalization
of those who are mentally ill through exposure to the criminal justice system 14], 18], 19]. Anecdotally, transportation to a police station in the current study was attributed
to geographic efficiency so that the first responder police and NPACER could meet
in a timelier manner. However, further investigation is required to thoroughly describe
the pragmatic, circumstantial, and procedural processes that may explain this diversion
to a potentially restrictive environment and if such diversion required subsequent
presentation to an ED.

Limitations

This study relied on retrospective data collected for reporting purposes and may be
susceptible to selection bias as duplicate cases across the period were treated as
independent episodes. Furthermore, the cross-sectional comparisons were time limited
with no indication of the impact of the model on longitudinal outcomes such as the
length of stay for those who entered into acute mental health inpatient services or
on crisis relapse. Limitations in the research design give little insight into the
economic implications of the model, sustainability of the model or its applicability
to other area mental health services or jurisdictions. Furthermore, stakeholder (clinicians,
police, people in crisis, and their families) perceptions of the benefits and limitations
of the model are required to fully evaluate its impact. Further research which addresses
these limitations is required.