Table 3 Box quotations

1) Main reasons for using psychiatric emergency departments (ED) based on individual patient interviews:

a) Inadequacy of mental health services in responding to their needs

“Family doctors are not qualified on the subject. It takes the psychiatrist. The family doctor cannot treat psychological problems!” (Brief intervention team-MB11139)^a

“I have the impression that doctors or other clinicians do not know what to do with someone who is suffering or that they are able to explain well what the person has. You know it’s like I’m not taken seriously.” (Brief intervention team-SCG11126)

“I don’t think doctors or clinicians in general are qualified to handle complex cases and maybe they take things a little too personally.” (Crisis center team-AM22228)

“At the local community health service center, when I went there to get information, the person I met was rushed. I was not lucky. I did not come across someone who had compassion and wanted to help me.” (Crisis center team- MD22202)

“Only specialized treatment is insufficient for her.” (Family-peer support team-JJ33304)

b) Problems with access to mental health services

“Yes, apart from the fact that everything that is private is chargeable, when I approach a local community health service center and not a walk-in clinic, there was a 6 month wait just to get an evaluation. What do I do with myself during all this time? Well I end up back here at the ED. What do you want me to do?” (Brief intervention team- CV11134)

“I tried to call three places to see, to have a psychiatrist, and then everyone passed to buck to me. I was constantly told that I was in the wrong place when I called the number the doctor had given me. It’s really badly organized, leaving patients to commit the irreparable, because you feel completely abandoned by the system. If I didn’t have the ED, I don’t know what I would have done.” (Brief intervention team-MM11114)

“Services other than the ED are generally closed when we need them.” (Crisis center team- IG22220).

“Sometimes services are needed quickly, and unfortunately getting access to services other than the ED can take a long time.” (Family-peer support team-CL33319)

c) Problems with continuity of mental health services

“It is difficult to get a follow-up for medication. When you start a medication, it can be difficult after that to find a doctor who is willing to continue the treatment and follow up with the patient, to maybe change the dose and accompany him along the way. It’s difficult to find.” (Brief intervention team- LG11137)

“I had services, but the continuity has been broken.” (Crisis center team-IG22220).

“Sometimes users need more services. When outpatient services are not enough, they are sometimes forced to go to the ED.” (Family-peer support team-CL33319)

2) Conditions for successful innovation according to staff (Focus groups with managers and clinicians)

a) Health system: Underfunding

“Another challenge is that we are the least funded crisis center in Montreal. We would have wanted a liaison agent, who could work a full day at the ED every week. But it isn’t possible with the staff we have now.” (Crisis center team-01)^b

“But I think the major weak point is money. Less than half of our budget comes from government on a stable basis. This is a major challenge.” (Family-peer support team-01)

Long delay to find long term follow-up in the community

“Unfortunately, the entire network is very bogged down, whether primary or specialized services. Thus, the delays are long before patients receive follow-up, which means that they are kept on the team longer and the caseload increases.” (Brief intervention team-01)

Primary care provided by two integrated university health service centres

“We refer people to the primary care clinic close to our ED, which is not in the same integrated health service center as us. So, we sometimes have major communication challenges. There are many different contact persons to speak with, and sometimes we encounter barriers.” (Brief intervention team-03)

b) Inter-organizational relationships: Culture clashes

“Well from the outside, we had a credibility problem. We are a community organization, a non-profit organization. We were viewed as volunteers rather than professionals, whereas we have had a very professional team right from the beginning. We were a team of professionals that wanted to work in the community, but we were not always considered professional. So we faced accountability, credibility issues. We had to build trust. Because having people referred to us brings a lot of responsibility with it; we were in two completely different practice cultures.” (Crisis center team-01)

“I think that’s probably the most serious challenge. Because it’s really about changing culture, changing mindsets; and who are we to change the hospital culture? Changing mindsets is really something that the hospital has to think about. So we do what we can, but I think there is some progress.” (Family-peer support team-01)

c) Organization: Manager turnover

“In the past few years, the ED has had six different medical chiefs. So each time we certainly had to “resell” the crisis center team, reestablish links, recreate the partnership. Because a lot depends on individual will at the ED, the people with whom we need to chat, collaborate, address difficulties. So that kind of change can take us a few steps back rather than advancing.” (Crisis center team-01)

Problems of office space

“Access to offices, how to get that at the ED? It has always been complicated. We don’t have a key or an access card. We can’t move around. This is still an issue today.” (Crisis center team-01)

“We have a lack of space, and it’s not just me! I sometimes don’t have an office where I can meet families.” (Family-peer support team-04)

Delay before patients receive their ED discharge

“We get stuck in the ED discharge process, because we often have to wait to receive “the go ahead” from the ED psychiatrist who authorizes patient discharges, which allows us to transfer patients to the crisis center.” (Crisis center team-02)

d) Clinician: Turnover

“While some psychiatrists helped us a lot to move forward, as soon as they left things fell back! There are good practices that we had started to implement, but then slacked off.” (Crisis center team-03)

“There are 15 different psychiatrists working in the ED, all of them part-time, and turnover is high.” (Crisis center team-04)

Absence of interest or knowledge

“Whenever Dr. M… tried to meet with other ED doctors and explain to them what the brief intervention team was, the doctors did not show up. We tried several times, and there were only one or two doctors, and always the same ones who came; the others didn’t. So, the ED doctors aren’t thus very aware of what brief intervention entails.” (Brief intervention team-02)

e) Patients: Profiles more difficult to follow-up

“Co-occurring disorders are incredibly prevalent! Especially those involving use of substances like amphetamines. This contributes to the high incidence of individuals with suicidal ideation who end up at the ED; this just cannot be! Or alcoholics as well: people with alcohol problems...” (Brief intervention team-04)

“People with autism spectrum disorder are complex to treat and refer to outpatient services.” (Brief intervention team-05)

“As for people in the justice system for serious crimes, we are not really equipped to treat them, I would say.” (Crisis center team-02)

“Also those with aggressive behaviors, it’s difficult to get their cooperation.” (Crisis center team-04)

“People with antisocial personality disorders are very difficult to deal with.” (Crisis center team-01)

“Whether psychotic or not, the person who is very, very distrustful, who has a paranoid profile, poses a challenge. We have many clients with this profile. For example, we have some who only talk about people following them on the street, or neighbors who persecute them, and we can’t talk about anything else, so that’s the problem.” (Crisis center team-01)

Patients estranged from their families

“Because there are ED users who are admitted with police escort or things like this. Sometimes the families are contacted a week or two after patients are admitted. Sometimes patients have been missing for months; they no longer have family contact.” (Family-peer support team-03)

Patients who do not allow ED professionals to contact their families

“Let’s say that a patient comes to the ED based on a psychiatric assessment order, and then systematically refuses to allow us to contact their family. We don’t necessarily have access to the family right away.” (Family-peer support team-04)

Aggressive or overly critical family members

There are sometimes families that I am not comfortable referring to the family-peer support team, because they are too aggressive. There are also at times families who, unfortunately, have behaved inappropriately in their contacts with the ED. In those cases, I would not be comfortable leaving them alone with the family-peer support team. For example a man who shouts at everyone; then I send this man out for a walk. I can understand that the man is probably in distress, but the fact remains that I don’t want to put the family-peer support team in this situation.” (Family-peer support team-03)

3) Most valued intervention features according to patients or family members (Individuals interviews)^a

a) Quality of the contact

“I appreciated the fact that the doctor listened to me. He took the time to understand what I was saying and managed to read between the lines.” (Brief intervention team-CV11134)^a

“Their welcome, the human approach, their friendliness and compassion, their honesty, the fact that they put us at ease in the center. They come to the ED to see us. Once at the crisis center, we meet with them at least once a day. This service was great; it went well for me. I was stressed. It helped me a lot to see clearly how to deal with problems in my life. The center was very organized; they had accommodation rules. The people who stayed with me were respectful. Overall, I had a great experience.” (Crisis center team-CG22226)

“The crisis center where we can get a short period of respite: it’s a warm house; it’s surrounded by trees.” (Crisis center team- VS22230)

“People help each other. People love each other. They want to help others. It’s an incredible feeling. That’s why I love the place.” (Crisis center team- VN22226)

“I found the representative from the family-peer support team very sensitive, listening. I felt that they really wanted to help me.” (Family-peer support team-LC33306)

b) Quality of treatment

“I appreciated the availability, the professionalism of the team, the fact that I was not left in the dark about medication changes. Information about the medication and side effects was clearly explained to me. They also explained the other steps that could be followed to get better.” (Brief intervention team-MG11123)

“We offer comprehensive psychosocial support that goes beyond medication management only.” (Crisis center team- AS22203)

“They made sure I got the information. They made sure the information was useful to me. This was the part I liked the most.” (Family-peer support team-KM33313)

c) Access to care

“What I appreciated was that I could see a clinician quickly, and that I could call them when I had important problems that stressed me. They listened, and helped me to overcome my problems.” (Brief intervention team-EG11132)

“It’s a welcoming environment where you can get support even during the night, which I didn’t use, but it was possible.” (Crisis center team-AS22203)

“I really appreciated the availability of the phone service 24 h a day.” (Crisis center team- MD22202)

“I appreciated that the help was immediate when I spoke to them.” (Family-peer support team- KM33313)

d) Continuity of care

“They called me often to remind me that I had an appointment, to see how I was doing with the medication.” (Brief intervention team-MB11140)

“I really appreciated that they were following up people like me on a daily basis. I really enjoyed being able to speak with someone on the team every day.” (Crisis center team- LM22237)

“When I called them, and they had to call me back, and when they told me they would send me resources, they did. They were quick. They followed me well.” (Family-peer support team- KM33313)