Psychiatric emergencies without psychiatric preparation: A contemporary challenge for Emergency Medical Services

The global rise in mental illness has led to an increasing need for assessment of patients with mental health issues within Emergency Medical Services (EMS). ¹ Currently, almost one in seven individuals lives with a mental disorder. ² Due to the increasing prevalence of mental illness, mental health issues have become one of the top five reasons for ambulance dispatch. ³ Often, EMS is the first point of contact for patients entering the healthcare system in many cases, playing a vital role in the initial assessment of mental health issues. ⁴ Mental health emergencies require relational assessment, communication and time-intensive evaluation, in contrast to the rapid assessment and intervention model that traditionally characterises EMS care. Traditionally, education in prehospital care focuses on somatic diseases and injuries with quick assessments and direct medical measures rather than on mental illness. Hence, there is a discrepancy between the curriculum and the daily work of the EMS clinician.

A report from the National Board of Health and Welfare ⁵ indicates that there is a great need to further educate EMS clinicians on mental health issues; for example, when assessing and caring for patients with severe mental disorders and patients who are suicidal. Swedish studies show that EMS clinicians feel that they have insufficient knowledge and education about psychiatric diseases and caring for these patients in prehospital settings.^6,7 This highlights the need for more education on mental health during studies. More importantly, it reflects a broader structural problem.

To further explore this important and timely issue, we argue that the growing gap between the mental health care demands placed on prehospital nurses and the support structures intended to guide their practice represents more than a simple mismatch. It exposes a systemic misalignment within EMS: while clinicians are routinely required to manage complex mental health presentations, the educational curriculum, clinical guidelines and organisational infrastructure remain predominantly shaped around somatic emergencies. As a result, nurses carry responsibility for an area of care that the system itself has not prioritised, operationalised or adequately equipped them for. Recognising this as a structural design issue rather than an individual competence deficit is essential for understanding why perceived preparedness remains low despite increasing exposure to mental health emergencies.

From a systems perspective, contemporary EMS remains structurally organised around rapid somatic assessment, treatment and stabilisation, despite the growing prevalence and complexity of psychiatric emergencies. This creates a structural misalignment in which clinical demands evolve faster than educational models, operational guidelines and organisational support systems. In such complex care environments, competence cannot be understood solely as an individual attribute but must be viewed as a system-dependent capability shaped by training, infrastructure, decision-support and feedback mechanisms. This framing underpins our interpretation of EMS practice.

To illustrate how this structural imbalance unfolds in practice, we draw on experiences from Swedish EMS. These data are used here to illustrate system design implications rather than to present standalone empirical findings. Survey data from two EMS organisations in southwestern Sweden provide an example of how prehospital nurses perceive their preparedness to care for patients with mental illness, and how educational background, clinical experience and guideline support shape perceived competence.

Experiences reported in survey material from Swedish EMS organisations illustrate that EMS personnel frequently encounter patients with mental illness, yet the level of support they perceive from existing regional guidelines varies considerably. Rather than reflecting individual variation among nurses, this inconsistency points to differences in organisational preparedness and guideline implementation. Importantly, nurses who perceived the guidelines as supportive also reported higher levels of perceived competence, demonstrating how organisational structures rather than personal attributes shape EMS care.

The usability of guidelines is not a new topic, but a recurrent issue, as adherence to prehospital guidelines has long been recognised as problematic, with studies showing low compliance in multiple areas. ⁸ Low adherence to guidelines often has several causes, including their design. Many guidelines are developed by individuals who do not work in prehospital settings, which can result in formats that are difficult to use in practice. The physical format, often static paper-based formats, further limits usability during direct patient care. As a result, guidelines are frequently consulted only after a mission, primarily to confirm that decisions made in the field were correct. ⁹ Consequently, improving guideline usability is a systemic responsibility of the clinical organisations. The next generation of guidelines must be co-designed with EMS clinicians to ensure they are digitally integrated and function as active decision-support tools that are usable during, rather than only after, complex patient encounters. In practice, this includes embedded pathways for suicide-risk assessment, de-escalation and communication support, as well as structured psychiatric decision guidance usable at the point of care.

A notable tension emerges in clinicians’ descriptions of mental health care in prehospital settings. While many express little concern about encountering patients with mental illness, they simultaneously describe limited confidence in their own knowledge and ability to provide appropriate care. This combination demonstrates that lack of preparedness is not driven by fear or reluctance, but by recognised gaps in education and clinical support. This observation reflects a broader structural problem. The growing gap between the mental health care demands placed on prehospital nurses and the support structures intended to guide their practice represents more than a simple mismatch.

Nurses’ demographics also suggest that perceived competence in managing mental illness is closely shaped by prior experience and educational background. Those with psychiatric work experience or postgraduate prehospital training describe greater knowledge, confidence and leadership in patient-centered care. This pattern points to education and exposure as key enablers of competence, while also highlighting persistent variability within the EMS workforce. Such variation raises questions about the equity and consistency of mental health care provided in prehospital settings.

Clinical experience in psychiatric settings strengthens clinicians’ perceived ability to care for patients with mental illness in a prehospital setting. EMS education should therefore incorporate structured psychiatric placements and simulation-based mental health training. Feedback on patient assessment and outcomes is crucial for developing competence in prehospital care. This is clearly equally important for patients with mental health issues. To address this, closer collaboration between hospital organisations and ambulance services requires structured feedback and simulation-based training focused on assessing patients with mental illness must be integrated into postgraduate education curriculums and continuing professional development to enhance professional practice.

In summary, mental health emergencies are no longer an exceptional aspect of prehospital care but a routine part of EMS practice. Yet, education, guidelines and organisational structures continue to reflect a predominantly somatic focus. This mismatch places EMS clinicians in a position of responsibility without adequate preparation or support and raises concerns regarding patient safety in mental health emergencies. Repositioning mental health competence as a core component of prehospital education, supported by usable guidelines and opportunities for clinical feedback, is essential to ensure safe, equitable and sustainable care. Addressing this issue is a matter not only of individual competence, but also of organisational responsibility within contemporary emergency medical services.

Ultimately, this reflects a structural design problem that requires reform of the care delivery model rather than incremental adjustments to individual competence. As long as mental health emergencies are managed within systems designed for somatic crises, EMS clinicians will continue to carry responsibility without support. This is not a gap within the system; it is a failure of the system itself.