Patients with mental health disorders face a ‘mixed bag’ of experiences with medical care in the ER

Many people with mental health or substance use disorders experience stigma and perceived biases when seeking medical care—not directly related to their mental health—in a hospital emergency department (ED/ER), according to research by the University of Massachusetts Amherst.

Other ER patients with mental health or substance use disorders reported a more positive experience when seeking care for their physical health.

“We found a mixed bag of experiences,” says Linda Isbell, the Feldman-Vorwerk Family Professor in Social Psychology at UMass Amherst and lead author of the study published in the journal Health Services Research. “We didn’t find all negative experiences, which is what I think a lot of people might have expected.”

The new paper is the final in a series of three by Isbell and team about challenges and experiences in the ER, often an overcrowded, under-resourced environment that reflects the dysfunction of the U.S. health care system. The first paper, published in 2020, looked at how the emotions of ER health care providers might affect patient care. The second paper, from 2023, examined how ER physicians and nurses treat patients who have mental health and substance use issues.

“So now we turned to the patients’ experiences,” Isbell says, and specifically to a vulnerable group.

“There were definitely a good number of people who identified what they perceived to be stigma in health care providers, with statements like, ‘You know, they were treating me really well. But then they looked at my chart and saw that I was being treated for opioid addiction, and then everybody started treating me like s—t.’ And they attributed that to stigma, which, frankly, is probably right,” Isbell says.

That patient experience lines up with Isbell’s previous findings that some doctors and nurses in the same ER acknowledged “they do sometimes engage in behaviors that are not ideal, like certain people with substance use disorders or people with mental health issues might not get the kind of attention they need,” Isbell says.

The research team identified patients at an academic medical center in the Northeast who came to the ED with a physical health issue and whose medical record indicated a mental health or substance use disorder. Fifty patients agreed to be interviewed onsite in the ER and over the phone about two weeks later. The interviews took place between February 2018 and January 2019.

Patients with negative perceptions described health care providers as “dismissive,” “rushed” and “unprofessional.” Many of the patients had complaints of pain, including chest and abdominal.

“They complained about providers not listening, believing that their illness was due to anxiety, but it was actually due to some physical illness,” Isbell says. “That’s called diagnostic overshadowing, attributing a physical illness to a mental health condition or substance use disorder.”

On the other side, some patients expressed positive experiences, describing doctors and nurses as “attentive,” “communicative,” “efficient” and providing “quality care.”

“I was very heartened to see that there were some definite positives that people pointed out. They thought their care was excellent. They thought that they got what they needed,” Isbell says.

She also points out that many ER patients have the same complaints and experiences as those with mental health and substance use disorders; however, she notes that research suggests the impact and magnitude of these negative experiences may be greater among those with these disorders.

“I think one of the challenges across patient populations is that there’s this mismatch between the expectations that patients sometimes have and what the ER can actually provide,” Isbell says. “I’ve often advocated, as in this paper, too, that we need to better educate patients about what the ER can and can’t do.”

The findings suggest that education for consumers and training for doctors and nurses could improve the ER experience for both patients and health care providers. But ultimately, systematic reform is the badly needed solution.

“We have a crisis in health care, and the ER is the safety net for all of these individuals who can’t get care elsewhere,” Isbell says. “You have people coming into this high-risk, crowded environment with things that don’t need care at an ER, but they have nowhere else to go. And then that can take away time and resources and energy from people who have true emergent concerns and issues.”

The paper concludes, “Reform to our health care system is urgently needed to ensure quality care for all—particularly our most vulnerable members of society.”