The prevalence of delaying psychiatric care until the patient has received ‘medical clearance’, and the definitions and understanding of ‘medical clearance’ terminology by relevant clinicians, are largely unknown. In a service evaluation of adult liaison psychiatry services across England, we explore the prevalence, definitions and understanding of ‘medical clearance’ terminology in three parallel studies: (a) an analysis of trust policies, (b) a survey of liaison psychiatry services and (c) a survey of referring junior doctors. Content and thematic analyses were performed.

‘Medical clearance’ terminology was used in the majority of trust policies, reported as a referral criterion by many liaison psychiatry services and had been encountered by most referring doctors. ‘Medical clearance’ was identified as a common barrier to liaison psychiatry referral. Terms were inconsistently used and poorly defined.

Many liaison psychiatry services seem not to comply with guidance promoting parallel assessment. This may affect parity of physical and mental healthcare provision.

Psychiatric patients visiting the Emergency Department (ED) often require ‘medical clearance’. We aim to review patient work-up in the ED to facilitate the management of these patients.

- To identify common demographic variables, diagnoses and mental health legislative status of patients presenting to the ED requiring psychiatric admission - To assess whether patients underwent a medical work-up in the ED, and what investigations were carried out - To produce a hospital proforma for the management of psychiatric patients presenting at the ED

Data on adult psychiatric patients visiting the ED over a six month period was collected retrospectively, which was then analysed accordingly.

473 patient admissions were reviewed. 32.8% were admitted to a non-psychiatric specialty before being accepted to psychiatry, with the most common reasons being due to overdose (30.3%), alcohol-related problems (19.4%), and medical complaints (18.7%). 63.2% of all patients were investigated in the ED, including 23.5% undergoing CT Brain imaging. The majority had a final diagnosis falling under F10-19 (30.2%) and F30-39 (30.9%) chapter categories of the ICD-10, with the former having the highest absolute number of patients undergoing testing in the ED. The F20-29 group (13.7%) was highest in total patients investigated (75.4%), CT brain imaging (56.9%), and rate of involuntary admissions (33.8%), suggesting they are the most resource intensive group.

Patients with acute mental disorders present significant challenges to emergency physicians. Staff education and an inter-departmentally agreed upon proforma, taking into account the results of this study, may facilitate management of these patients within the ED.

To investigate recognition of diagnostic overshadowing, i.e., misattribution of physical symptoms to mental illness, among emergency medicine professionals; further, to identify contributory and mitigating factors to diagnostic overshadowing.

In-depth individual interviews of 25 emergency department clinicians and qualitative analysis using thematic analysis.

Diagnostic overshadowing was described as a significant issue. Contributing factors included: (1) problems of knowledge and information gathering; (2) clinicians' attitudes toward people with mental illness, substance misuse and frequent attenders; and (3) difficulties in working with mental health services in the context of a 4-h target for discharge from the emergency department. Avoidance of patients with a psychiatric diagnosis was also described, due to fear of violence.

The physical health care of people with mental illness in emergency departments may be adversely affected by diagnostic overshadowing and avoidance by clinical staff, along with difficulties created by the illness, medication and the emergency department environment. Greater joint working between psychiatric and emergency department staff is suggested as one way to reduce diagnostic overshadowing.