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Date: September 18, 2025

Guest Skeptic:  Dr. Neil Dasgupta is an Emergency Medicine (EM) physician and emergency department (ED) intensivist from Long Island, NY. He is the Vice Chair of the ED and Program Director of the EM residency program at Nassau University Medical Center in East Meadow, NY. 

Reference:  Doupnik et al. Impact of telemental health on suicide prevention care in U.S. emergency departments. AEM Sept 2025

Trigger Warning: The following case scenario discusses suicide and self-harm. If you or someone you know is at risk, seek immediate help (dial 911/999/112 as appropriate, or 988 in the US/Canada for suicide & crisis support).

Resources: 

  • Substance Abuse and Mental Health Services Administration (SAMHSA)
  • National Alliance on Mental Illness (NAMI)
  • American Foundation for Suicide Prevention (AFSP)

Case: It’s 23:15 on a Tuesday in a 10-bed rural emergency department (ED) that serves as the community’s sole hospital. A 37-year-old male arrives with a friend after texting that they “can’t do this anymore.” The friend is concerned because he has access to firearms. Triage vitals are stable. The nurse uses the ED’s standard suicide‑risk screen, which is positive. The nurse activates the service’s 24/7 telemental‑health workflow. A video cart is wheeled into the room, and a remote clinician joins the conversation.

Background: Delivery of quality mental health care is one of the major difficulties affecting our EDs. Caring for these patients presents a particular kind of challenge, since establishing rapport with the patient, getting a detailed history, gathering collateral information from others, overcoming possible intoxications or toxidromes, requiring staff for continuous observation and treating physical injuries can require substantial levels of time and skills. 

In addition, suicide remains a leading cause of death, and EDs are a frequent point of contact for people in crisis. Many of these encounters involve complex psychosocial factors, limited outpatient capacity, and time-sensitive safety planning. The stakes are high, and what happens in the ED can shape risk in the hours to days after discharge.

As emergency physicians, we balance therapeutic alliance, thorough risk assessment, and efficient disposition in an environment built primarily for acute medical care, not longitudinal mental health follow-up. Frustration often occurs due to limited resources, high volumes, inpatient boarding and overcrowding; it can seem impossible for an ED physician to provide compassionate, nuanced, complete psychiatric care.

Patients utilize the ED for mental health care because they often do not have a choice.  Sometimes that lack of choice stems from a report of suicidal thoughts, which in most communities represents a lack of capacity to make medical decisions, and EMS systems are required to transport these patients for emergent psychiatric care.  In many communities, especially in areas that have less robust access to health care in general, there are profound administrative, financial and systemic barriers to creating or maintaining a functional level of mental health care infrastructure, profoundly overburdening the services that exist and pushing those needs onto the local emergency departments. 

Telemedicine (particularly telepsychiatry and broader telemental health) has become a pragmatic way to expand access to mental health expertise. This has accelerated with the pandemic-era virtual care. Programs vary widely, with some providing on-demand psychiatric prescribers, while others lean on social work, psychology, or case management. Integration with the ED team and the electronic health record (EHR) can be excellent in some settings and minimal in others.

Despite legislative progress in the US, including the Affordable Care Act and the Addiction Equity Act, reimbursements remain poor for the care of such patients, severely limiting access to care.  As with many other challenging issues, for lack of a better option, the ED becomes the entryway to any portion of the healthcare system.

For rural and critical‑access hospitals, telemedicine can be the difference between no specialist input and round-the-clock access. But the question that matters to front-line EM clinicians is not just “Is telehealth available?” It’s “Does telehealth meaningfully improve the way we deliver suicide‑prevention care in the ED?”And, even if processes improve, do those changes translate into better patient-oriented outcomes (POO) such as reduced attempts, ED revisits, or suicide deaths?

Clinical Question: Among US hospital-affiliated EDs, is having access to telemental health associated with greater routine use of recommended suicide‑prevention practices?

Reference:  Doupnik et al. Impact of telemental health on suicide prevention care in U.S. emergency departments. AEM Sept 2025

  • Population: 606 EDs in the US associated with a general medical hospital
    • Excluded: EDs in government hospitals (VA/DoD), specialty hospitals (orthopedic), rehabilitation hospitals, and independent children’s hospitals (surveyed separately). Freestanding EDs not affiliated with a general hospital.
  • Exposure: ED use of telemental health (telepsychiatry/telemental services available to the ED). 
  • Comparison: EDs without telemental health. Analyses stratified by critical‑access hospital status and adjusted for ED/hospital characteristics. 
  • Outcome:
  • Primary Outcome: Routine use of six recommended suicide‑prevention practices
    1. Assessment of current suicidal intent/plans
    2. Past suicidal thoughts/behaviours
    3. Access to lethal means
    4. Standard approach to discharge planning
    5. Routinely scheduling follow-up
    6. Lethal‑means restriction counselling.
  • Secondary Outcomes: Prevalence and characteristics of ED telemental health programs (staffing, hours, and EHR integration).
  • Type of Study: A National cross-sectional survey with stratified probability sampling and nonresponse weighting.

Dr. Stephanie Doupnik

This is an SGEMHOP, and we are pleased to have the lead author on the episode, DrStephanie Doupnik is an Assistant Professor of Pediatrics and Health Policy and Director of the Division of Pediatric Hospital Medicine at Vanderbilt University Medical Center. Dr. Doupnik’s research has been funded by the National Institute of Health and focuses on the implementation of mental health services and suicide prevention care in EDs and hospitals, including the use of telehealth.

Authors’ Conclusions: “Telemental health care is widely used across all types of EDs, and EDs with telemental health care are more likely to use suicide prevention practices. Critical-­access hospitals rely on telemental health care to a great extent and need better access to telehealth psychiatry and EHR information sharing.

Quality Checklist for Reporting of Survey Studies (Yes/No/Unsure)?

  1. Were hypotheses or aims explicitly stated? Yes
  2. Were operational definitions of the predictor (independent) and outcome (dependent) variables provided? Yes
  3. Were participant eligibility criteria (inclusion and exclusion) explicitly stated? Yes
  4. Were participants recruited using an acceptable recruitment strategy? Yes
  5. Were participants selected by a random/probability sampling strategy? Yes
  6. Was the sample size appropriate? Unsure
  7. Were participants randomly assigned into groups/ conditions? N/A
  8. Was the response/participation/recruitment rate provided? Yes
  9. Was the attrition rate acceptable? Unsure
  10. Was the attrition rate treated appropriately in data analyses? Yes
  11. Were the chosen statistical tests appropriate to address hypotheses or research questions? Yes
  12. Did the study include a formative research or pilot phase? Yes
  13. Were the measures provided in the report (or in a supplement) in full? Yes
  14. Were all measures of established validity, or was a validation procedure undertaken by the authors? Unsure
  15. Was the study sample described in terms of key demographic characteristics? Yes
  16. Was the data collection process described with sufficient detail for it to be replicated? Yes
  17. Were generalizations of findings restricted to the population from which the sample was drawn? Yes
  18. Was the study approved by a relevant institutional review board or research ethics committee? Yes
  19. Did participants provide informed consent (or assent, where relevant)? Yes
  20. Were funding sources or conflicts of interest disclosed? Yes 

Results: Of 977 eligible EDs, 606 responded (62%), weighted to 4,321 EDs nationally. Responders more often were rural, smaller, and critical‑access hospitals with nonresponse weights applied. Overall, 68% of responding EDs reported using telemental health. Lower ED volume, smaller bed size, and critical‑access status were associated with higher telehealth use.

Key Result: Over two-thirds of US emergency departments use telemental health.

  • Secondary Outcomes: 
    • Availability: More than 80% of telehealth EDs reported 24/7 coverage, with critical‑access EDs reporting they were more likely to have 24/7 access (81% vs 64%). 
    • Staffing: Telepsychiatrists/prescribers available in 68% of non-CAH programs vs 54% in CAHs. CAHs relied more on private contractors/other systems. 
    • EHR Integration: Telehealth clinicians could view the EHR in 64% of non-CAHs vs 28% of CAHs; documentation privileges 64% vs 35%. 
    • Post‑ED Follow‑Up: Only about one quarter of programs provided any follow-up after discharge.

Listen to the SGEM podcast to hear Stephanie answer our five nerdy questions.

  1. Self‑Report & Social Desirability Bias: Outcomes were ED leaders’ reports of “routine” practice. Without chart audits or direct observation, overestimation is plausible, especially for practices perceived as best‑practice (lethal‑means counselling). How did you mitigate this issue?
  2. Cross‑Sectional Design & Confounding:Telehealth presence may proxy for institutional culture, leadership, staffing ratios, or parallel quality initiatives (Zero Suicide) that themselves drive better processes. Despite covariate adjustment, could unmeasured confounding be responsible for better practice and not telehealth specifically?
  3. Response Rate: Rural and smaller hospitals were more likely to respond. Nonresponse weighting helps, but if nonresponders differ on unmeasured variables (burnout, turnover, local mental‑health capacity) that could impact the estimates of the effect
  4. Measurement Heterogeneity.“Telemental health” encompassed diverse modalities and staffing models (from social work–led to psychiatrist‑led), and “routine use” of practices was not externally standardized. Misclassification (both in exposure and outcome intensity) could attenuate or inflate associations. 
  5. Multiplicity & Model Specification: Six outcomes were modelled independently. Without adjustment for multiple comparisons, some statistically significant findings could represent chance positives. Additionally, potential clustering within health systems and varying telehealth maturity could influence variance estimates. 

Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: The study successfully described patterns of use of tele-mental health in EDs throughout the US, and we agree with their conclusions.  

SGEM Bottom Line: Access to telemental health in US EDs (especially rural critical access hospitals) is associated with more consistent suicide‑prevention processes, but evidence that it improves patient‑centered outcomes is still lacking.

Case Resolution: The combination of ED staff and telemental health support allowed for a thorough suicide risk assessment, including discussion of current intent and access to lethal means. A collaborative plan was created to remove firearms from the home and secure medications, while also developing a personalized safety plan. Given ongoing suicidal intent and limited local outpatient options, the decision was made to transfer the patient to an inpatient psychiatric care.

Clinical Application: If your ED has, or is planning to use telemental health, consider prioritizing the five following things:

  1. Operationalizing standard work for intent/plan and lethal‑means assessments
  2. Embedding lethal‑means counseling into the workflow
  3. Ensuring EHR viewing and documentation access for teleclinicians
  4. Seeking psychiatry‑prescriber involvement when possible
  5. Building post-ED follow-up capacity to address the high-risk period after discharge.

Dr. Neil Dasgupta

What Do I Tell the Patient?  Thank you for coming to the ED with your friend and being open about how hard things have been. You are not alone in this, and tonight we are focused on keeping you safe. Having suicidal thoughts is concerning. Your friend has agreed to lock up your firearms or move them out of the house for now. We’re also arranging for you to go to a hospital where you can get more support and care for how you’re feeling.

Keener Kontest: Last week’s winner was Joshua McGough. He knew TENS units are believed to work through the gate theory of pain.

Listen to the SGEM podcast for this week’s question. If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode.

Now it is your turn, SGEMers. What do you think of this episode on telemental health? What questions do you have for Stephanie and her team? Post your comments on social media using #SGEMHOP. The best social media feedback will be published in AEM.

Other SGEM Episodes:

  • SGEM#360: We Care a Lot – The EmPATH Study
  • SGEM#313: Here Comes A Regular to the ED
  • SGEM#252: Blue Monday- Screening Adult ED Patients for Risk of Future Suicidality
  • SGEM Xtra: Everybody Hurts, Sometime
  • SHED Talk: Gateway Lecture on Farmers’ Mental Health

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.