Psychiatric Emergency Service Research Articles

Characteristics of Older Adults With Serious Mental Illness Enrolled in a Publicly Funded In-Home Mental Health Treatment Program

In-home mental health services for older adults will likely become increasingly utilized as the population ages. Little is known about older adults with serious mental illness who receive in-home services through the public mental health system. This study examined the demographic and clinical characteristics of this population. A total of 148 clients were included. Mood disorders were present in 75.7% and schizophrenia spectrum disorders were present in 23.6%. A history of problematic substance use was documented in 47.3% of clients and 31.8% reported suicidal ideation prior to enrollment. A total of 25% of clients utilized psychiatric emergency services during the year prior to enrollment and 15.5% of clients were hospitalized for psychiatric treatment. Older adults who receive in-home mental health services are vulnerable and have complex treatment needs.

Predictors of recurrent use of psychiatric emergency services.

Many patients visit psychiatric emergency services several times per year, which raises questions about the limits of this treatment setting. Previous studies have focused on recurrent visits over one year of follow-up. This study examined sociodemographic and diagnostic predictors of recurrent visits (three or more visits a year) to a psychiatric emergency service over three consecutive years. This three-year retrospective cohort study used data from computerized administrative and medical records of 4,322 patients who visited the psychiatric emergency service of the University Hospitals of Geneva, Switzerland, at least once in 2008. A total of 210 (5%) of the 4,322 patients had three or more visits in 2008. Of these, 22% also had recurrent use (three or more visits per year) in 2009, 2010, or 2011, and 78% did not. Recurrent visits were not predicted by sociodemographic characteristics, such as age, gender, marital status, professional activity, and citizenship. Two variables were significant predictors of recurrent visits: a diagnosis of a personality disorder and recurrent use of the emergency service in the 18 months before study entry in 2008. Patients with personality disorders and past recurrent use of emergency services appeared to rely more on psychiatric emergency services for continuous psychiatric care than patients without past recurrent use of emergency services and patients with mood, substance use, anxiety, or psychotic disorders. Creation of a follow-up treatment program for this clinical population within the psychiatric emergency setting itself may provide better access to care for these patients.

Crianças e adolescentes usuários de substâncias no serviço de emergência psiquiátrica

Objetivo Descrever as características de crianças e adolescentes que utilizaram o serviço de emergência psiquiátrica devido aos transtornos pelo uso de substâncias analisando a freqüência e desfechos dos atendimentos. Métodos Estudo transversal realizado em serviço de emergência psiquiátrica sendo considerado o atendimento aos menores de 18 anos correspondentes ao uso de substâncias. Resultados Foram realizados 4.198 atendimentos de emergência psiquiátrica para crianças e adolescentes. Destes, 1.007 eram por problemas relacionados ao uso substâncias, com idade prevalente de 12 aos 17 anos, com predomínio da cor branca, cursando ensino fundamental, religião católica e policonsumo. A maioria foi internada ou recebeu alta. Conclusão Foi possível caracterizar os atendimentos de emergência psiquiátrica, destacando a idade precoce, o policonsumo e a não continuidade de tratamento como aspectos críticos.

Helping Children in Acute Psychiatric Crises

Helping Children in Acute Psychiatric Crises

Aggression and Psychosis in Patients Seeking Emergency Psychiatric Care in New Delhi, India

Background/Context: There is high risk of violence and aggression in the medical emergency care settings (MECS) of which psychiatric services constitute an important part, forming lateral entry points for patients into the mental health care system. Psychosis has been imposed as the predominant cause for majority of aggressive presentation in MECS. There is scarcity of Indian data towards this facet. Objective(s): The aim of the study is to explore the principal reasons for referral to a psychiatric emergency and explore the disorders most commonly associated with violent and aggressive behavior. Methodology: This cross sectional descriptive study evaluated consecutive psychiatry referrals from the emergency ward for duration of six months at a tertiary care center. Data was gathered using a semi structured proforma and analyzed by SPSS version 17.0. Diagnosis of schizophrenia or related psychotic disorders (SRPD) and other psychiatric disorders was ascertained via ICD-10. Result(s): Majority of the overall emergency psychiatry referrals presented with aggression (42%) with no significant gender difference. About 72% of aggressive subjects were diagnosed with psychiatric disorders, of which 28% suffered from SRPD. Delirium and affective disorders constituted 12% and 16% of the aggressive subjects respectively, while diagnosis could not be ascertained in 28% subjects. Of the 462 referred cases, 13.6% subjects were suffering from SRPD. About 85% of these subjects presented with aggressiveness and behavioral disturbance. Apart from 12% previously diagnosed cases of SRPD, 88% of the subjects were new cases. Conclusion: Aggressive behaviour is the principal presentation in psychiatric emergency services, and schizophrenia & related psychosis contribute a significant proportion of these cases. There is a high rate of previously undiagnosed subjects seeking treatment in emergency, highlighting the role of emergency psychiatric services in not just acute crisis management but also in initiating long term treatment.

Video-confidence: a qualitative exploration of videoconferencing for psychiatric emergencies.

BackgroundIn psychiatric emergencies in rural areas the availability of psychiatrists are limited. Therefore, tele-psychiatry, via real-time videoconferencing (VC), has been developed to provide advanced consultative services to areas that lack psychiatrists. However, there is limited research on the use of VC for psychiatric emergencies. The University Hospital of North Norway has been the first hospital in Norway to implement this type of service by developing a new on-call system for psychiatric emergency practice through which psychiatrists are accessible by telephone and VC 24 hours a day for consultations with patients and nurses at three regional psychiatric centres. This study explores patients’, psychiatrists’ and nurses’ experiences of using VC for psychiatric emergencies, as well as how the technology influenced their confidence.MethodsIn this study, we used a qualitative explorative research design. With a particular focus on users’ experiences of VC, we conducted 29 semi-structured interviews with patients, psychiatrists and nurses who had participated in a VC consultation in at least one psychiatric emergency.ResultsOur findings show that access to the VC system increased the experience of confidence in challenging psychiatric emergencies in four ways: (1) by strengthening patient involvement during the psychiatric specialist’s assessment, (2) by reducing uncertainty, (3) by sharing responsibility for decisions and (4) by functioning as a safety net even when VC was not used.ConclusionsThis study has demonstrated that an emergency psychiatric service delivered by VC may improve the confidence of psychiatrists, nurses and patients in challenging psychiatric emergencies. VC can serve as an effective tool for ensuring decentralised high-quality psychiatric services for emergency care.

The paediatric psychiatric emergency population in a university teaching hospital in Belgium (2003–2008)

In the last few decades, there has been a remarkable increase in the number of children and adolescents presenting with psychiatric complaints to the emergency department in the USA. In Europe, however, less is known about the paediatric psychiatric emergency population. This study provides a clinical and demographic profile of this population and its service use in a European context. From 2003 to 2008, we registered 989 paediatric psychiatric patients consulting the psychiatric emergency services (PES) of a large university hospital in Belgium. During this period the number of patients increased more than three-fold. Patients were predominantly female (57.3%) and adolescent (83.3%) and mostly referred for hostility and violence towards others (18.5%) and suicidal ideation (17.8%). For about 1/4 of the patients, PES was the first ever mental health treatment contact. PES could serve as a place for early detection and intervention and as an entry point to mental health services.

Adolescents reçus en urgence en psychiatrie infanto-juvénile. Qui sont-ils ? Quel est leur parcours ? Quel suivi social et/ou judiciaire ?

In recent years, the number of emergency consultations by teenagers in child and adolescent mental healthcare centers/psychiatric facilities has increased significantly worldwide. Minors monitored by child welfare services (both social child care services and youth judicial protection services) are overrepresented among these adolescents consulting in emergency. ObjectivesWe wanted to study the differences between adolescents consulting in emergency and adolescent consulting in routine, programmed consultation, particularly items such as: personal and family psychological history, diagnosis, social and/or legal trajectory. We also wanted to explore whether adolescents receiving social and/or legal support are overrepresented in this population and show specificities with regard to, for instance, their personal and family history, their clinical manifestations, their health care access and trajectories… Patients and methodsAn unprecedented national multicenter scheme was set up, consisting of 10 teams of public child and adolescent psychiatric departments, well distributed on the French territory and selected on a voluntary basis. During 4 months, after each consultation, trained physicians collected the data used in this study, by filling out a computerized grid, titled “Life course and treatment of children and adolescents”, which includes 83 items. ResultsFour hundred and thirty-three adolescents were included, and we collected complete data for 330 consultations. The data outline the characteristics of adolescents using the psychiatric emergency services in France, which are in keeping with the international literature. They highlight the fragility of their environment, and how they are much more subject to a chaotic trajectory. We were able to identify the overrepresentation of adolescents followed by child welfare services (both social and judicial), which appear as a relevant indicator of turbulences in the lives of these teenagers. Indeed, they are often a consequence of failing early interactions or later abuse. The youth having the most issues, and especially with the legal system, are those having, in their history or currently, the more psychopathological disorders. In a second phase, focusing more specifically on adolescents who receive social and/or judicial support, we showed that they were mainly experiencing externalizing problems (F90 to F92 in ICD-10), which require continuity and longtime care. Numerous and distressing separations in the past of these teenagers are at play once again in the way they chose to use emergency consultation, instead of programmed ones. This consistency, so much needed, can be achieved through the establishment of working partnerships between the different professionals in charge of these adolescents, as an answer to the internal and external chaos they experience. ConclusionThe emergency consultations are useful, but they are also indicative of the need to reinforce care upstream for these adolescents. Their therapeutic management requires an organization designed to tackle their chaotic trajectory: continuity and institutional cooperation are the cornerstones of a specific treatment. A prospective study could explore more precisely the nature of the supports which are offered afterward to these adolescents and evaluate their efficiency.

Who's boarding in the psychiatric emergency service?

IntroductionWhen a psychiatric patient in the emergency department requires inpatient admission, but no bed is available, they may become a “boarder.” The psychiatric emergency service (PES) has been suggested as one means to reduce psychiatric boarding, but the frequency and characteristics of adult PES boarders have not been described.MethodsWe electronically extracted electronic medical records for adult patients presenting to the PES in an urban county safety-net hospital over 12 months. Correlative analyses included Student’s t-tests and multivariate regression.Results521 of 5363 patient encounters (9.7%) resulted in boarding. Compared to non-boarding encounters, boarding patient encounters were associated with diagnoses of a primary psychotic, anxiety, or personality disorder, or a bipolar manic/mixed episode. Boarders were also more likely to be referred by family, friends or providers than self-referred; arrive in restraints; experience restraint/seclusion in the PES; or be referred for involuntary hospitalization. Boarders were more likely to present to the PES on the weekend. Substance use was common, but only tobacco use was more likely associated with boarding status in multivariate analysis.ConclusionBoarding is common in the PES, and boarders have substantial psychiatric morbidity requiring treatment during extended PES stays. We question the appropriateness of PES boarding for seriously ill psychiatric patients.

ICD-10 mental and behavioural disorders due to use of crack and powder cocaine as treated at a public psychiatric emergency service: An analysis of visit predictors

The present study investigated the predictors of an increased number of visits from individuals with some of the diagnoses noted in chapter F14 of ICD-10, from calls to the emergency psychiatric unit of a general hospital in São Paulo state, Brazil, in the period 2011–2012. Poisson regression models were carried out for the outcome variable, accounting for number of subsequent visits to the psychiatric emergency unit. For the analysis of this outcome we took into account the exposure time of each individual in the study. Our findings point to a population at risk for frequent psychiatric emergency service visits: individuals over 25 years. This population should be targeted for interventions on entry into public healthcare due to increased psychiatric morbidity and greater clinical morbidity already confirmed by previous studies. We discussed the need of these individuals for special attention during the clinical or psychiatric emergency consultation which, unfortunately, may be the access point for the public health system. None of the other variables were related to the outcome of interest, such as those related to the level of individual entry into the care network before and after treatment, and other variables related to medical acts during the visit.

Associations between reasons for living and diminished suicide intent among African-American female suicide attempters.

African-American women are at high risk for suicide ideation and suicide attempts and use emergency psychiatric services at disproportionately high rates relative to men and other ethnic groups. However, suicide death rates are low for this population. Cultural variables in the African-American community may promote resilience and prevent fatal suicidal behavior among African-American women. The present study evaluated self-reported reasons for living as a protective factor against suicidal intent and suicide attempt lethality in a sample of African-American female suicide attempters (n = 150). Regression analyses revealed that reasons for living were negatively associated with suicidal intent, even after controlling for spiritual well-being and symptoms of depression. These results indicate that the ability to generate and contemplate reasons for valuing life may serve as a protective characteristic against life-threatening suicidal behavior among African-American women. Implications for research and clinical practice are further discussed.

The number of emergency department visits for psychiatric emergencies is strongly associated with mean temperature and humidity variations. Results of a nine year survey

Several disorders, such as renal colics, stroke, atrial fibrillation and others, are epidemiologically associated with seasonality and microclimatic variations. Although evidence is still limited, an association between psychiatric emergencies and seasonality has also been previously described. In order to elucidate the possible association between weather and incidence of psychiatric emergencies in a country with temperate climate, we analyzed the influence of day by day climate changes on the number of visits for psychiatric emergencies in an urban emergency department (ED) of northern Italy. All ED visits for psychiatric emergencies were retrieved from the hospital database from 2002 to 2010. The total number of ED visits was 725,812 throughout the study period, 11,786 of which for emergency psychiatric problems. We found a strong seasonal distribution of emergency psychiatric visits, peaking in summer and at the beginning of spring. The linear regression analysis showed a strong positive association between number of daily emergency psychiatric visits and mean daily air temperature (R=0.82; P<0.001), and an inverse association with mean daily air humidity (R=-0.52; P<0.001). These findings suggest that psychiatric disorders follow a significant seasonal variation, so that it may be advisable to strengthen psychiatric emergency services during the hottest months.

Predicting Future Suicide Attempts Among Adolescent and Emerging Adult Psychiatric Emergency Patients

The purpose of this study was to longitudinally examine specific characteristics of suicidal ideation in combination with histories of suicide attempts and non-suicidal self-injury (NSSI) to best evaluate risk for a future attempt among high-risk adolescents and emerging adults. Participants in this retrospective medical record review study were 473 (53% female; 69% Caucasian) consecutive patients, ages 15 to 24 years (M = 19.4 years) who presented for psychiatric emergency services during a 9-month period. These patients' medical records, including a clinician-administered Columbia-Suicide Severity Rating Scale, were coded at the index visit and at future visits occurring within the next 18 months. Logistic regression models were used to predict suicide attempts during this period. Socioeconomic status, suicidal ideation severity (i.e., intent, method), suicidal ideation intensity (i.e., frequency, controllability), a lifetime history of suicide attempt, and a lifetime history of NSSI were significant independent predictors of a future suicide attempt. Suicidal ideation added incremental validity to the prediction of future suicide attempts above and beyond the influence of a past suicide attempt, whereas a lifetime history of NSSI did not. Sex moderated the relationship between the duration of suicidal thoughts and future attempts (predictive for male patients but not female). Results suggest value in incorporating both past behaviors and current thoughts into suicide risk formulation. Furthermore, suicidal ideation duration warrants additional examination as a potential critical factor for screening assessments evaluating suicide risk among high-risk samples, particularly for male patients.

Substance use disorders in hospitalized psychiatric patients: The experience of one psychiatric emergency service in Turin

In the present study we sought: 1) to estimate the frequency of substance use disorders (SUD), and 2) to investigate whether there is a mere association between diagnosis and SUD in a large cohort of patients with severe psychiatric disorders representative of the usual setting and modality of care of a psychiatric emergency service in a geographically well-defined catchment area in Italy, independent of sociodemographic features, anamnestic data and clinical status.The study was conducted between January 2007 and December 2008. The following rating scales were performed: the Clinical Global Impression-Severity (CGI-S), the Global Assessment of Functioning scale (GAF) and the Brief Psychiatric Rating Scale (BPRS). Factors found to be associated (p<0.05) with SUD[+] in the univariate analyses were subjected to multilevel logistic regression model with a backward stepwise procedure.Among 848 inpatients of our sample 29.1% had a SUD codiagnosis. Eleven factors accounted for 30.6% of the variability in SUD[+]: [a] a Personality Disorder diagnosis, [b] a Depressive Disorder diagnosis, [c] male gender, [d] previous outpatient contacts, [e] single marital status, [f] no previous psychiatric treatments, [g] younger age, [h] lower scores for BPRS Anxiety-depression and [i] BPRS Thought Disturbance, [l] higher scores for BPRS Activation and [m] BPRS Hostile-suspiciousness.The findings are important in identifying (1) the complexity of the clinical presentation of SUD in a inpatients sample, (2) the need for collaboration among health care workers, and (3) the need to develop and apply treatment programs that are targeted at particular risk groups.

Demand and characteristics of a psychiatric 24-hour emergency service performed by mandatory rotation of licensed psychiatrists in Swiss primary care

BackgroundTo investigate characteristics of and satisfaction with psychiatric 24-hour emergency primary care performed by mandatory rotation of licensed psychiatrists as a viable baseline for possible reorganizational measures.MethodsThis was a questionnaire-based cross-sectional study (November 2010–April 2011). The number of patient–psychiatrist encounters, modes of contact, and patient and psychiatrist characteristics were assessed. Diagnoses were coded with ICD-10 (International Classification of Diseases, version 10).ResultsFrom 167 duty episodes, 74 (44%) were recorded. Of the psychiatrists (n=44), 52% were female, and mean age (standard deviation) was 49.9 (5.2) years. The median number of encounters per episode was 4 (interquartile range 0–8), mainly in the evenings. Demand for “face-to-face” (direct) patient visits was significantly more common (64.0%) than practice (1.3%) or telephone consultations (34.7%). In 83.8%, psychiatrists judged the encounter as adequate at the patient’s location. A total of 43 different diagnoses were recorded: mainly schizophrenic disorders (23.9%), suicidal behavior (15.2%), and acute stress reactions (10.3%). Psychiatrists felt burdened by services (62.5%): in 39.2%, they felt threatened; and in 6.8%, violence occurred. In 32.4%, bills were not paid for. If services were optional, 45.2% would participate.ConclusionOur findings indicate justified demand for direct mobile patient visits, suggesting that emergency care should be multifaceted, and sole provision of psychiatric care at stationed emergency facilities may not always be appropriate. Reorganization of 24-hour emergency services should carefully evaluate patient and provider’s needs before changing established structures.

Effect of a Regional Dedicated Psychiatric Emergency Service on Boarding and Hospitalization of Psychiatric Patients in Area Emergency Departments

IntroductionMental health patients boarding for long hours, even days, in United States emergency departments (EDs) awaiting transfer for psychiatric services has become a considerable and widespread problem. Past studies have shown average boarding times ranging from 6.8 hours to 34 hours. Most proposed solutions to this issue have focused solely on increasing available inpatient psychiatric hospital beds, rather than considering alternative emergency care designs that could provide prompt access to treatment and might reduce the need for many hospitalizations. One suggested option has been the “regional dedicated emergency psychiatric facility,” which serves to evaluate and treat all mental health patients for a given area, and can accept direct transfers from other EDs. This study sought to assess the effects of a regional dedicated emergency psychiatric facility design known at the “Alameda Model” on boarding times and hospitalization rates for psychiatric patients in area EDs.MethodsOver a 30-day period beginning in January 2013, 5 community hospitals in Alameda County, California, tracked all ED patients on involuntary mental health holds to determine boarding time, defined as the difference between when they were deemed stable for psychiatric disposition and the time they were discharged from the ED for transfer to the regional psychiatric emergency service. Patients were also followed to determine the percentage admitted to inpatient psychiatric units after evaluation and treatment in the psychiatric emergency service.ResultsIn a total sample of 144 patients, the average boarding time was approximately 1 hour and 48 minutes. Only 24.8% were admitted for inpatient psychiatric hospitalization from the psychiatric emergency service.ConclusionThe results of this study indicate that the Alameda Model of transferring patients from general hospital EDs to a regional psychiatric emergency service reduced the length of boarding times for patients awaiting psychiatric care by over 80% versus comparable state ED averages. Additionally, the psychiatric emergency service can provide assessment and treatment that may stabilize over 75% of the crisis mental health population at this level of care, thus dramatically alleviating the demand for inpatient psychiatric beds. The improved, timely access to care, along with the savings from reduced boarding times and hospitalization costs, may well justify the costs of a regional psychiatric emergency service in appropriate systems.

Substance Misuse in the Psychiatric Emergency Service; A Descriptive Study

Substance misuse is frequently encountered in the psychiatric emergency service (PES) and may take many forms, ranging from formal DSM-IV diagnoses to less obvious entities such as hazardous consumption. Detecting such patients using traditional screening instruments has proved problematic. We therefore undertook this study to more fully characterize substance misuse in the PES and to determine whether certain variables might help better screen these patients. We used a prospectively acquired database of over 18,000 visits made to four PESs during a 2-year period in the province of Quebec, Canada. One of the variables acquired was a subjective rating by the nursing staff as to whether substance misuse was a contributing factor to the visit (graded as direct, indirect, or not at all). Substance misuse accounted for 21% of all diagnoses and alcohol was the most frequent substance used. Patients were divided into those with primary (PSM), comorbid (CSM) or no substance misuse (NSM). Depressive disorders were the most frequent primary diagnoses in CSM, whereas personality and substance misuse disorders were frequent secondary diagnoses in PSM. Although many variables significantly differentiated the three groups, few were sufficiently detailed to be used as potential screening tools. Those situations that did have sufficient details included those with a previous history of substance misuse, substance misuse within 48 hours of the visit, and visits graded by the nursing staff as being directly and/or indirectly related to substance misuse. Variables related to substance misuse itself were the primary predictors of PSM and, less significantly, CSM. The nursing staff rating, although promising, was obtained in less than 30% of all visits, rendering its practical use difficult to assess.

EPA-0449 – Profile of psychiatric emergency visits in a university hospital in south of brazil

Over the Last decades outpacients services become a substitute for psychiatric hospitals in Brazil. For most patients, Psychiatric emergency Services represents the entry point into health care system and an essential source of treatment. The Psychiatric Emergency Service of the University Hospital of Santa Maria (SEP/HUSM) has operated since 1972 and serves the 537,745 inhabitants of 31 municipalities in southern Brazil. To describe the profile of SEP/HUSM visits in the years 2010 and 2011. Define the profile and the quality of care of visits to SEP/HUSM. Evaluate the characteristics of the visitas in SEP/HUSM during the years 2010 and 2011 to compare the statistics with other services. This is a cross-sectional study of 7853 visitas, with the data of a questionnaire defined in the SEP/HUSM, associated with the records of the HUSM and using demographics and clinical variables. Research approved by the ethics committee HUSM. The majority of the patients are from Santa Maria (83,9%), male (52%), 25-44 years old, had Mood Disorders (39%) and Substance Dependence (28,3%), came to the SEP/HUSM during the weekdays, and were sent to the observation room (21.5%) or hospitalized (18,9%). The profile of the care provided in the SEP/HUSM is similar to other centers. There is a great demand by patients without the appropriate profile of treatment in the SEP/HUSM, probably due to problems in the other units of the mental health system.

Urgent and nonurgent presentations to a psychiatric emergency service in Nigeria: pattern and correlates.

Psychiatric emergencies are acute mental health disturbances that require immediate intervention. However, the emergency department is increasingly being utilised for nonurgent mental health problems, thereby compromising the quality of care available for patients with urgent problems. This study assessed the level and correlates of urgency of mental health problems among patients presenting to an emergency department in Nigeria. The Crisis Triage Rating Scale, Clinical Global Impression Scale and a supplementary questionnaire were administered to 700 attendees at the emergency department of the Federal Neuro-Psychiatric Hospital Yaba, Lagos. Only 29.1% of the presentations constituted an “emergency” 10.9% were “urgent,” while 60% were “nonurgent.” The most common reason for nonurgent presentations was the need for medication refill. On regression analysis, level of urgency of presentations was independently associated with employment status, need for medication refill, substance abuse, suicidality, routine clinic attendance, and use of physical restraint before presentation. The majority of visits to the emergency department are for apparently “nonurgent problems.” However in a resource-poor setting, the emergency department may be the only safety net for the attendees. Our findings point to a need for education of service users and policy shifts in mental health care financing and organisation.

Predictors of frequent visits to a psychiatric emergency room: A large-scale register study combined with a small-scale interview study

BackgroundThe role of the psychiatric emergency services has undergone extensive changes following a significant downsizing of the number of psychiatric hospital beds during the past decades. A relatively small number of “frequent visitors” accounts for a disproportionately large amount of visits to psychiatric emergency services. ObjectivesTo identify predictors of frequent use of a psychiatric emergency room at a Danish University Psychiatric Hospital through a 12-year period (1995–2007) and to speculate on how changes in the mental healthcare services affect predictors of frequent use through time. DesignA large-scale register based logistic regression analysis combined with a small-scale explorative, interpretative interview study. Register data were drawn from the Danish Central Psychiatric Research Register. Four-year cohorts (1995, 1998, 2001 and 2004) of patients with at least one visit to the psychiatric emergency room were followed for 3 years to identify general trends of predictors throughout the period. A purposeful sample of 15 frequent visitors were interviewed about their personal motives for visiting the psychiatric emergency room, their pathways to care, and their social network and social support. ResultsThe study identified two overall trends of predictors of frequent use of the psychiatric emergency room. High use of psychiatric services: ≥5 visits to the psychiatric emergency room, ≥3 admissions or ≥60 bed days during the year, was and continued to be predictive of high use of the psychiatric emergency room throughout the whole period. Furthermore, the emergence and continual presence of the predictors: severe mental illness (1999-onwards), substance abuse (2002-onwards) and sheltered housing (2002–2003–2005-onwards) indicated changes in the general profile of frequent visitors to the psychiatric emergency room, where predictors related to illness behaviour were supplemented by predictors related to disease. ConclusionThe changing profile of the conditions predicting frequent visits at the psychiatric emergency room was most probably related to the adverse effects of the continuous deinstitutionalising of the Danish mental health services and a radical health care reform. A basic multiplicative model was designed for the early detection of individual frequent visitors.