The distinctive features of psychiatric on-call work

All on-call work is demanding, and emergency work in all specialities involves uncertainty and risk. However, out-of-hours psychiatric work has some distinctive features that are particularly relevant to training and service design. Compared with many acute medical and surgical presentations, out-of-hours psychiatric assessments rely less on the results of medical tests and investigation and more on history, collateral information, mental state examination, formulation, and risk assessment conducted in real time and often in challenging environments. Presentations frequently involve a complex mix of mental illness, acute distress, suicidality, self-harm, substance-related symptoms, behavioural disturbance, psychosocial crisis, and uncertainty about the most appropriate setting for care.

Assessments are necessarily relational and often time-intensive, requiring careful attention to context, collateral information, prior contact with services, and the meaning of symptoms and risk within the person’s wider situation. While consultant supervision is available, it is frequently at a distance, and other multidisciplinary colleagues are often not accessible out of hours.

Acute risk assessment is a particularly pressurised component of on-call psychiatry. In practice, complex formulations are often compressed into binary decisions about admission, discharge, or onward referral, despite limited information and high uncertainty. Short-term risk prediction remains imprecise, and expectations of certainty, particularly in retrospect, can be unrealistic. In this context, safety planning, clear documentation, senior support, and shared responsibility across disciplines and services are essential.

Emergency departments often become the default site of response for a wide range of presentations at the interface of health, mental health, and social care, with psychiatry drawn into a significant portion of these, depending on clinical need, risk, and available pathways.

Why psychiatry on call has become busier

The growing intensity of psychiatric on-call work reflects a convergence of systemic, societal, and service-level changes more than any generational change amongst trainees.

Reduced stigma, greater recognition of mental health difficulties, and broader expectations of timely intervention have increased help-seeking, while development of services has remained uneven across community, emergency, and out-of-hours pathways (Mental Health Reform and Ipsos 2018). Presentations related to psychological distress, suicidal ideation, self-harm, substance use, housing insecurity, migration-related stress, and the enduring effects of the COVID-19 pandemic all contribute to increasing demand (Duggan et al. Reference Duggan, Harris, Chislett and Calder2020; Hartnett et al. Reference Hartnett, Alshurafa, McAndrew, Daly, Alsaffar, Cotter, Cannon, MacHale, Murphy and Barry2023). Longitudinal data from Irish community mental health services demonstrates a marked increase in referral volume over time, alongside a shift towards more urgent referrals and referrals characterised by suicidal risk and emotional crisis (Douglas and Feeney Reference Douglas and Feeney2016).

The national population has grown and become more diverse, requiring services to respond to greater clinical, social, ethnic and linguistic complexity. At the same time, inpatient bed capacity has reduced, and community services have not expanded consistently in line with need.

Emergency departments have increasingly become holding environments for people presenting with mental health crises, including many with suicidal ideation, self-harm, substance-related presentations, or acute behavioural disturbance (Mental Health Commission 2025; National Suicide Research Foundation 2025). In parallel, the uneven development of alternatives to hospital attendance and admission – including crisis resolution or home treatment teams, rapid access clinics, acute community-based assessment pathways, and peer-led community cafés – has made decisions about care more resource-dependent and variable across settings.

In addition to clinical demand, the workload associated with documentation, governance, communication across teams, and repeated assessment in the absence of integrated electronic records has increased significantly. These factors have transformed on-call psychiatry from episodic emergency work into sustained crisis management within a resource-constrained system.

The service user experience out of hours

For service users and families, out-of-hours mental health care is often encountered at moments of heightened fear, distress, and uncertainty (Bull and Kisely Reference Bull, Goh, Warren and Kisely2024). These encounters are rarely experienced as part of a system; instead, they are lived as a single interaction, assessment, or decision.

The environment in which care takes place, whether a crowded emergency department, an acute hospital ward, or a stand-alone psychiatric unit, shapes perceptions of safety, dignity, privacy, and support. Emergency departments are often busy and overstretched, with limited space for therapeutic engagement. While psychiatric facilities may feel isolated and frightening. Prolonged waiting, repeated assessments, and lack of privacy can compound distress.

In Ireland, the absence of integrated electronic records adds to the duplication and fragmentation of care, particularly for individuals with repeated presentations. Staff safety concerns in out-of-hours settings further underscore the intensity of these encounters and the close relationship between service-user and staff safety.

Trust is built, or eroded, in these moments. When clinicians are supported to work reflectively and collaboratively, service users are more likely to experience care as containing and respectful, even where definitive resolution is not possible in a single encounter.

Who presents out of hours

The population presenting out of hours is diverse. Many individuals do not have severe or enduring mental illness, although others do, including some already known to services. Presentations may involve acute distress related to social adversity, relationship breakdown, homelessness, or emotional pain; others involve suicidal ideation, self-harm, substance-related symptoms, behavioural disturbance, or complex interactions between these factors (Gallagher et al. Reference Gallagher, Hunt, Kelly and Ivers2025; Griffin et al. Reference Griffin, Arensman, Perry, Bonner, O’Hagan, Daly and Corcoran2018).

In many cases, psychiatry is asked to respond not only to mental illness or acute risk, but also to problems arising from unmet social need, barriers to accessing care, and limitations in service pathways. A proportion of individuals presenting in crisis are already open to mental health services, raising important questions about access, responsiveness, and continuity of care (McLoughlin et al. Reference McLoughlin, Abdalla, MacHale and Barry2021).

Certain groups are particularly affected by current system limitations, including adolescents, people with intellectual disability or neurodevelopmental conditions, older adults with complex comorbidities, and individuals experiencing homelessness or substance use difficulties. These groups are more likely to experience fragmented pathways, and environments that do not meet their needs.

These patterns raise questions about how best to organise crisis response across disciplines, and about when psychiatric assessment is required versus when alternative responses may be more appropriate.

Equity, trust, and lived experience

Qualitative studies of emergency mental health care highlight experiences of noise, crowding, lack of privacy, and feeling unsafe, alongside the importance of being listened to and treated with respect (Bull and Kisely, 2024). People from marginalised groups are more likely to encounter delayed assessment, repeated handovers, and coercive practices, which can deepen mistrust and deter future help-seeking.

Recognising these inequities and involving people with lived experience in service design is essential if out-of-hours psychiatry is to be experienced as safe, legitimate, and responsive.

Supervision and training in context

The supervisory relationship between consultant and NCHD remains central to safe and effective out-of-hours care. The College of Psychiatrists of Ireland position paper emphasises the importance of clear roles, structured induction, simulation training, handover processes, multidisciplinary support, and sustainable rostering (Blamey et al. Reference Blamey, Harrison, Roddick, Malhotra and Saunders2023; Crowley et al. Reference Crowley, McDonagh, Carolan and O’Connor2024; Naxakis et al. Reference Naxakis, Wafer, Gardezi, Sadia, Mujahid and O’Connor2025).

Preparation for on-call work should also include site-specific induction, including an introduction to emergency department processes, and opportunities for shadowing or supervised exposure prior to independent work. Clear expectations regarding escalation and senior review are essential.

However, supervision alone cannot compensate for wider structural issues, including understaffing, inappropriate environments, and a lack of administrative and multidisciplinary support.

Training, service quality, and stewardship

Services that prioritise training, education, and supervision are more likely to deliver safe and effective care. Attention to on-call work therefore represents an opportunity for system stewardship.

Recent investment in emergency department mental health nursing and expansion of crisis services reflects recognition of current pressures. Further alignment between training structures and service design, alongside reduction of non-clinical burden and protection of rest and recovery, can support more considered and sustainable care.

System responses and service configuration

Certain service configurations can make on-call psychiatry safer and more sustainable. These include multidisciplinary out-of-hours responses, timely psychiatric input within emergency departments, acute assessment pathways linked to mental health units, crisis resolution or home treatment teams, rapid access clinics, and clearer pathways for urgent review of patients known to services. However, effectiveness depends on staffing, governance, and alignment with existing services.

If implemented and sustained well, with clear consultant leadership, defined inclusion criteria and robust outcome monitoring, such developments could redistribute some of the burden currently carried by on-call psychiatry while improving access to care in more appropriate settings.

However, many presentations reflect unmet social need, including housing instability and poverty. Addressing these requires broader societal investment beyond healthcare alone.

Strengthening primary care and community responses, improving integration between services, and clarifying psychiatry’s role within the wider system are essential. Without this, on-call psychiatry will continue to function as a default response to a wide range of crises.

Looking outwards from on call

On-call work offers a unique window into the realities of mental health care, its urgency, its complexity, and its humanity. It is also where the strengths and limitations of the wider system are most visible.

Attending to the on-call experience offers an opportunity not only to support trainees, but to improve the quality, safety, and consistency of care provided to service users out of hours.

How we respond will shape not only the sustainability of the psychiatric workforce, but also the trust that service users and families place in mental health services when they need them most.