Study examines policies for transferring students with mental health emergencies from university to hospital

The chances that police will become involved in the care of a student who seeks help for their mental health on campus at an Ontario university health clinic depends on which university they attend, according to a new CAMH-led qualitative study published today in the journal CMAJ Open.

The study is believed to be the first in the world to conduct in-depth interviews with physicians to examine policies and processes for transferring students experiencing mental health emergencies from university clinics to hospital. Investigators found that some Ontario universities mandate the use of police restraints in all circumstances when students need emergency mental health hospital care, while others have policies that handcuffs only be used in rare circumstances as a last resort.

"We wanted to identify university policies that facilitated most dignified transfers to hospital from campus for students in need of emergency mental health care. We hoped such policies could serve as models for other universities," said lead author Dr. Andrea Chittle, a family physician who has worked in a university health clinic. "We learned that at some universities, handcuffs are being used every time. It is routine to convey students to hospital in handcuffs in all situations."

This work is especially timely, as mental illness among Canadian post-secondary students is increasing and mental health transfers ー when a student experiencing a mental health crisis is transferred from university health clinics to hospital for emergency psychiatric assessment and/or care ー are becoming more common.

The authors conducted interviews with 11 physicians at nine university health clinics in Ontario between July 2018 and January 2019. The interviews were confidential and the clinics were not identified to allow physicians to speak candidly about hospital transfer policies for students with mental health emergencies. At five of those clinics, police were always called to assist when a student needed to be transferred to hospital. At two of those clinics, police policy was to routinely use handcuffs during transfers of students to hospital.

Surveyed physicians at clinics where the handcuffing of students was common expressed concerns that it was traumatizing for students in a way that could deter them from seeking mental health supports in the future.

"To be taken in handcuffs and loaded up in a police cruiser seems brutal and traumatic for the patient and sends all the wrong messages about a caring, supportive environment," said one interview participant.

This study is the third collaboration of co-authors Drs. Andrea Chittle, CAMH Emergency Department Psychiatrist Juveria Zaheer and Shane Neilson, a student health clinic physician, examining mental health transfer policies at Ontario universities.

Their first paper identified the issue of police handcuffing of students in mental distress as an area of concern. The second paper reviewed policies and processes for transferring people experiencing a mental health crisis from community-based clinical settings to hospital. This latest study examined the decision to involve police and use handcuffs during mental health transfers, and alternatives to that practice.

The researchers found that the involvement of police and the use of restraints when students are in need of a transfer to hospital for psychiatric assessment is often due to non-clinical factors, such as understanding of staff roles and responsibilities, human resources constraints, and staffing implications of long emergency department wait times.

"Before I was in the system, I didn't realize how intertwined policing was with mental health," said undergraduate university student and study contributor Gina Nicoll, who has lived experience of mental illness including being transferred by police to hospital for assessment. "It just felt really disheartening and I felt defeated and powerless. It made me feel I was doing something wrong just by being unwell and I felt I was criminalized for it."

The authors conclude that routine police involvement in student mental health transfers to hospital is harmful. They suggest engaging police only in rare circumstances when the risk of a student fleeing or becoming violent during transfer to hospital is assessed to be high. They recommend that province-wide policies to minimize police use of restraints during mental health transfers from Ontario university clinics be developed in collaboration with university administrations, municipal and provincial governments, hospitals, police departments, and people with lived experience of mental illness.

As an emergency department psychiatrist, I see people on the worst days of their lives. People experiencing suicidal thoughts. People experiencing psychosis. They may be afraid. They may have trauma. They may not want to be there. Similarly, in university settings, we have people presenting in distress and crisis in a myriad of different ways, including students who are racialized and had experiences of oppression and negative interactions with police. Although we can't say that we never need to use restraints, they need to be used rarely and judiciously as a last resort. It should not be the default, because that is stigmatizing and frightening. We need to be trauma-informed and safe and to minimize restraint, just as we need to do in all healthcare settings."

Dr Juveria Zaheer, Study Senior Author and Emergency Department Psychiatrist, Center for Addiction and Mental Health

Dr. Chittle added that she hopes a public discussion over the role of police on campus will persuade universities to examine their policies and processes for students in mental health crisis. She notes that following her and her co-authors' previous work examining the practice of routinely engaging police and routine use of handcuffs at the University of Guelph, a more flexible procedure for hospital transfers was developed. At the same time, changes to police policies enabled the discretionary use of restraints when police were engaged in transfers.

"I think we are seeing society move more broadly away from police involvement in mental healthcare," said Dr. Chittle. "There are some pilot projects being undertaken that are non-policing models of mental health crisis care. My hope is that this is where we are going to move towards."