Abstract
BACKGROUND: Emergency department mental health practitioners (MHPs) decide onward care for individuals presenting with self-harm or suicidal ideation. However, their experiences and practices in making these decisions remain underexplored. AIMS: To synthesise research on MHPs' experiences and practices in making decisions about onward care for patients presenting to emergency departments with self-harm or suicidal ideation. METHOD: We searched six databases (inception to July 2024) for empirical studies of MHPs making care decisions for self-harm or suicidal patients in emergency departments. We used a segregated mixed-methods design, applying narrative synthesis of quantitative data and thematic synthesis of qualitative data. RESULTS: Eleven studies were included (one quantitative, one mixed-methods, nine qualitative). Narrative synthesis of quantitative data produced two themes: (a) subjective decision-making and variability among MHPs and (b) impact of the institutional mandate to discharge within 4 h on referral outcomes. Thematic synthesis of qualitative data generated five themes: (a) risk-centric culture is anti-therapeutic and shapes defensive practice, scepticism toward patients and burnout; (b) time and environmental pressures impact therapeutic potential of assessments; (c) 'battling' to access services: gatekeeping, cycles of repeat attendances affecting patient safety and staff moral injury; (d) strategies to facilitate access and extending care to overcome challenges in the emergency department and (e) potential for training to counter negative attitudes and stereotypes. CONCLUSIONS: Intersecting institutional, systemic and emotional pressures shape MHPs' practices, undermining assessment quality and access to care. System-level reforms and training should promote relational, compassionate care. Limited quantitative evidence restricted integration, and the review reflects high-income Western settings.