Psychiatric Emergency Service Research Articles

Bus Therapy

Crossing state lines, a man arrives alone in San Francisco, having traveled by bus on a 1-way ticket provided by a psychiatric hospital in his home state. He is disoriented,with few possessions,lacks medications and medical records, and calls 911 as he was instructed. He is brought to the county psychiatric emergency service, which,hectic and often over capacity,treats nearly 6000 patients annually (of which 39% are not San Francisco residents).The patient needs housing,a psychiatrist,case manager, primary care provider, and transfer of Medicaid or general assistance—a package known colloquially astheSan Francisco Special.Placements are challenging— the county hospital reduced its acute inpatient psychiatrycapacity50% in thelast 5years owing to budget short-falls—yet out-of-state visitors are not turned away. Shipping patients across state lines on 1-way bus fares without a treatment plan or identified residence is referred to as bus therapy, a form of patient dumping. In April 2013, the Sacramento Bee reported that more than 1500 mentally ill and questionably discharged patients from Nevada were transported by Greyhound bus to states across the country in the past 5 years.1 One-third were sent to California—San Francisco and Los Angeles counties initiated formal investigations. Patient dumping is not new. In the 1970s, with US mental health deinstitutionalization, psychiatric beds were reduced, uninsured patients were often turned away, and more patients sought emergency care. The 1986 Emergency Medical Treatment and Active Labor Act was intended to reduce patient dumping, by requiring emergency departments to screen and stabilize presenting patients (a subjective process). With continued reductions in inpatient capacity (4000 acute beds reduced nationally between 2010-2012), the impact on emergency services is expected to grow.2 People with mental illness have the right to relocate willingly and preferably when in stable condition and with facilitated continuity of care.On the other hand,patient dumping has many implications for psychiatric patients, especially the severely mentally ill. Obvious ones are potential harms owing to decompensation,poor self-care, loss of support networks, vulnerability to victimization, and/or failure to access care. In 2009, 40% of adults with serious mental illness went untreated.3

Regional Psychiatric Emergency Services: Good for Psychiatric Patients and EDs

In Alameda County, California, a regional psychiatric emergency services (PES) facility accepts all patients on psychiatric holds. Patients receive

APA Presses for Enforcement of Mental Health Parity Law

APA Presses for Enforcement of Mental Health Parity Law

Transforming Psychiatric Care Delivery in the Emergency Department: One Hospital’s Journey

Transforming Psychiatric Care Delivery in the Emergency Department: One Hospital’s Journey

Risk for physical restraint or seclusion in the psychiatric emergency service (PES)

ObjectiveWe describe risk factors associated with patients experiencing physical restraint or seclusion in the psychiatric emergency service (PES). MethodsWe retrospectively reviewed medical records, nursing logs and quality assurance data for all adult patient encounters in a PES over a 12-month period (June 1, 2011–May 31, 2012). Descriptors included demographic characteristics, diagnoses, laboratory values, and clinician ratings of symptom severity. χ2 and multivariate logistic regression analyses were performed. ResultsRestraint/seclusion occurred in 14% of 5335 patient encounters. The following characteristics were associated with restraint/seclusion: arrival to the PES in restraints; referral not initiated by the patient; arrival between 1900 and 0059 hours; bipolar mania or mixed episode; and clinician rating of severe disruptiveness, psychosis or insight impairment. Severe suicidality and a depression diagnosis were associated with less risk of restraint or seclusion. ConclusionAcute symptomatology and characteristics of the encounter were more likely to be associated with restraint/seclusion than patient demographics or diagnoses. These findings support recent guidelines for the treatment of agitation and can help clinicians identify patients at risk of behavioral decompensation.

P.1.k.014 Attenders of a Portuguese university hospital's psychiatric emergency service: general characteristics and gender differences

P.1.k.014 Attenders of a Portuguese university hospital's psychiatric emergency service: general characteristics and gender differences

Targeted Intervention Reduces Use in Frequent Users of Emergency Medical Services

Some of the increase in EMS use is driven by a small group of frequent users. Age, housing status, mental illness, and substance abuse have been identified as contributors to frequent use. Creating EMS-based outreach team could be a cost-effective means of reducing frequent use of EMS. We hoped to determine if engagement by the San Francisco Fire Department's (SFFD) Homeless Outreach and Medical Emergency (HOME) Team is associated with decreased EMS use, and to identify predictors of responsiveness to HOME team intervention. Patients who called EMS four or more times per month were identified from SFFD records and through referrals from EMS providers and EDs. Intervention began with a traditional paramedic assessment. Once patients were determined to not have any immediate medical need, the HOME TEAM Interventional Technique was employed. This includes direct transport to medical detoxification services, San Francisco Sobering Center, Psychiatric Emergency Services at San Francisco General Hospital (SFGH), substance abuse treatment clinics, primary care clinics, and access to case management and housing. We retrospectively analyzed data collected by HOME Team regarding EMS utilization in the 7 months before and after their intervention. Change in mean EMS use was the primary outcome measure. Social and demographic characteristics were gathered from the Department of Public Health EMR. Of the 59 subjects included in the final analysis, 14 subjects (nonresponders) had increased EMS use (mean increase 9.71, STD 9.75), and 45 subjects (responders) had decreased use (mean decrease 16.29, STD 18.88). The mean decrease in EMS use for all subjects was 10.1 calls per 7 months period (95% CI 4.4 - 15.9). None of the predictors were statistically associated with nonresponsiveness. HOME team intervention was associated with decrease in overall EMS use. While the response was not uniform, none of the tested factors predicted nonresponse. However, sample size limitations and high prevalence of some factors may have limited this finding. EMS-based outreach programs have the potential to reduce EMS utilization by frequent users.TablePatient Demographic and Social Characteristics.CharacteristicN = 59Sex, Male68%Mean Age in years (IQR)55 (9)Not Housed38.9% (5 missing)Substance Abuse88.9% (5 missing)Psychiatric History83.0% (6 missing)No primary Care Doctor43.4% (6 missing) Open table in a new tab

Toxic Effects of Psychotropics Related to Possible P450 Enzyme Inhibition by Kava: Report of 2 Cases

Kava is an herbal remedy popular for centuries among native Pacific Islanders for its sedative effects and use in religious ceremonies. Kava gained popularity in Western countries due to its anxiolytic properties; however, very little is known about potential adverse reactions to kava other than reports of hepatotoxicity. Two cases of patients seen on the psychiatric emergency and consult service who developed severe side effects from psychotropic medications in the context of kava use are presented. In both cases, kava use may have affected the metabolism of the psychotropic medications, leading to serious side effects. Growing research indicates that kava most likely alters concentrations of coadministered psychotropics possibly by inhibiting cytochrome P450 enzymes. This case series highlights the need for greater awareness of safety issues among kava users who also take medications that, when combined with kava, can be life-threatening at toxic levels. Pharmacogenomic testing along with further research about kava and its metabolites could help determine a pharmacologic solution for patients who require psychotropic medications but who would like to preserve cultural traditions and religious practices.

Educator Has Mastered Art of ‘Cerebral Jujitsu’

Back to table of contents Previous article Next article Residents’ ForumFull AccessEducator Has Mastered Art of ‘Cerebral Jujitsu’Michelle Marlborough, M.D.Michelle MarlboroughSearch for more papers by this author, M.D.Published Online:10 Sep 2013https://doi.org/10.1176/appi.pn.2013.8a19The Psychiatric Emergency Service (PES) at St. Michael’s Hospital in Toronto is a unique entity within the postgraduate training program. This site is part of a departmental focus on meeting the needs of a diverse inner-city population. Patients seen in crisis often have complex issues spanning substance abuse, homelessness, HIV infection, and poor access to services. Michelle Marlborough, M.D., B.Sc.N. (right), and Mara Goldstein, M.D.It is in this often chaotic environment that Dr. Mara Goldstein thrives. She is full of enthusiasm, passion, and humor. Medical students and residents consistently rate their time at the St. Michael’s Hospital PES as one of the highlights of their training.Dr. Goldstein knew she wanted to be a doctor at age 9, but it was a role-playing exercise focusing on personality disorders during medical school and a subsequent elective in emergency psychiatry with Dr. Mimi Israel that piqued her interest in psychiatry. After completing her undergraduate medical training at McGill University, she went to New York University for her psychiatry residency and pursued a fellowship in forensic psychiatry. Dr. Goldstein reflected in an interview on the influence of her mentors during residency, in particular Dr. Carol Bernstein, the late Dr. Wendy Reeves, and the various dedicated psychoanalytic supervisors who frequently held supervision in obscure bars and restaurants in Manhattan.Following graduation, she joined the staff at St. Michael’s Hospital, where she has worked for 10 years, with her primary area of interest being acute-care psychiatry. In addition, Dr. Goldstein served as director of undergraduate electives at the University of Toronto from 2007 to 2013 and recently began a part-time position as medical advisor at the College of Physicians and Surgeons of Ontario. Dr. Goldstein’s contributions to psychiatric education at the University of Toronto have been recognized with two recent honors. She received the 2012 Robin Hunter Award for Excellence in Postgraduate Teaching (which she likens to “winning an Oscar”) and the 2013 APA Irma Bland Award for Excellence in Teaching Residents. “I believe I can provide a balanced view of psychiatry with healthy skepticism, and after having had such good teachers myself, there was never a question of whether to be involved in education,” said Dr. Goldstein. She stated that her greatest reward is participating in the creation and development of psychiatrists as both professionals and people. Within emergency psychiatry, Dr. Goldstein maintains that “the cerebral jujitsu one has to master in order to be an effective teacher and clinician” keeps her on her toes and coming back day after day. Outside of the hospital, Dr. Goldstein summons her creative and innovative teaching methods to deliver informative seminars on topics such as human sexuality and pop culture, blending issues in psychiatry with media-related ones. Recent notable sessions have included “Dysfunctional Families and ‘Arrested Development’ ” and “Narcissism in ‘Tropic Thunder.’ ” Dr. Goldstein has a natural ability to bring challenging clinical concepts to life in meaningful and memorable ways. In the next 10 years, she envisions shifting her focus to public policy related to mental illness and aspires to one day be director of a psychiatry residency program. Along the way, she continually reminds residents of the importance of taking care of the self as “no one else is going to do it for you.” She is a keen proponent of “the art of doing nothing” during down time and balances her role as a devoted mother to three children with her professional life as a psychiatrist. I am grateful for Dr. Goldstein’s mentorship, and my clinical experiences with her have been the most formative aspects of my training thus far. She has a unique ability to verbalize her decision-making process and takes time out from working in a stressful environment to explain her understanding of complex patients. She is always mindful of the ways in which clinical experiences can affect residents and creates an open and supportive space in which to reflect. Her investment in my professional and personal success is without equal. When the end of residency arrives and I walk out the door, it will be Dr. Goldstein who helped me to put on my coat. ■Michelle Marlborough, M.D., is a PGY-3 psychiatry resident at the University of Toronto. ISSUES NewArchived

Food Insecurity Among Adults With Severe Mental Illness

Food Insecurity Among Adults With Severe Mental Illness

Perceived humiliation during admission to a psychiatric emergency service and its relation to socio-demography and psychopathology

BackgroundThere is a lack of empirical studies of patients’ level of humiliation during the hospital admission process and its implications for the clinical setting. We wanted to explore associations between self-rated humiliation and socio-demography and psychopathology in relation to admission to a psychiatric emergency unit.MethodsConsecutively admitted patients (N = 186) were interviewed with several validated instruments. The patients self-rated humiliation by The Cantril Ladder, and 35% of the sample was defined as the high humiliation group.ResultsFinal multivariate analysis found significant associations between compulsory admission, not being in paid work, high scores on hostility, and on entitlement, and high levels of humiliation. No significant interactions were observed between these variables, and the narcissism score was not a confounder concerning humiliation.ConclusionsHigh level of humiliation during the admission process was mainly related to patient factors, but also to compulsory admission which should be avoided as much as possible protecting the self-esteem of the patients.

Annual cost of relapses and relapse-related hospitalizations in adults with schizophrenia: results from a 12-month, double-blind, comparative study of lurasidone vs quetiapine extended-release

Purpose:To model the economic impact of annual relapses/relapse-related hospitalizations among adults with schizophrenia treated with lurasidone or quetiapine extended-release (XR).Methods:A probabilistic model estimating per-patient-per-year (PPPY) direct mental healthcare (MH) cost differences due to relapses/relapse-related hospitalizations was developed using relapse and relapse-related hospitalization rates from a 12-month, double-blind, parallel-group, global comparison study of lurasidone vs quetiapine XR (all patients previously treated with lurasidone or quetiapine XR for 6 weeks). Analyses were conducted for both all subjects and clinical responders. Direct costs associated with inpatient and outpatient mental healthcare-related services were obtained from a large, prospective, observational study of schizophrenia treatment in usual-care settings for relapsing and non-relapsing patients, including psychiatric hospitalizations, emergency services, medication management, and outpatient individual therapy. Model robustness was tested using univariate and probabilistic sensitivity analyses.Results:Model-estimated PPPY MH cost savings associated with relapse-related hospitalization rates in all subjects were $3276 for lurasidone vs quetiapine XR. Lurasidone resulted in PPPY MH cost savings of $2702 vs quetiapine XR in all subjects, using relapse rates. Sensitivity analyses indicated lurasidone had lower 1-year MH costs than quetiapine XR in 100% and 99.7% of simulations, using relapse-related hospitalization rates and relapse rates, respectively, in all subjects. Similar results were seen in clinical responders.Limitations:The model represents a simplification of treatment patterns and response to treatment. Cost of treatment with lurasidone and quetiapine XR was not included in the model. Estimates of cost savings are likely conservative, as the model did not assess the impact of long-term cardiometabolic consequences. Indirect costs associated with relapses and non-mental health-related costs were also excluded from the model.Conclusion:Adults treated for schizophrenia with lurasidone are predicted to have lower 12-month MH costs compared to those treated with quetiapine XR due to fewer relapses and relapse-related hospitalizations.

Usage de la contention en psychiatrie : vécu soignant et perspectives éthiques

The return of restraint in psychiatry raises many ethical issues for caregivers. However their experience is little explored in literature.Our objective was to study the feelings of caregivers facing restraint with regard to an ethical perspective and to identify areas for improvement.Between November 2011 and February 2012 a descriptive cross-sectional epidemiological study was performed in two psychiatric emergency services and two closed units in which doctors and nurses were individually interviewed using semi-structured questionnaires. Five topics were explored: indications and contexts, impact on the patient, caregiver-patient relationship, perspective on the practice and feelings of caregivers on which we insist particularly. Results were presented in tables with percentages and possibly diagrams. The notable responses of caregivers were also cited.Twenty nurses and nine psychiatrists, mostly female, were recruited. They all had participated in experiments of restraint. The self-aggressiveness, the aggressiveness against other persons and agitation were the most frequent indications. In the patients, caregivers identified misunderstanding (79.3%) and anger (75.9%). The majority of nurses (75%) felt that there was an improvement in the caregiver-patient relationship after the episode of restraint compared to what it had been in the moments preceding this measure. The emotional experience of caregivers was rich, intense and predominantly negative type of frustration (35% of nurses; 66.7% of doctors), anger (30 and 33.3%) and lack of feeling (35 and 44.4%). The feelings of doctors and nurses were not completely similar. For caregivers it was "a difficult but necessary experience" (82.75%), "an act of care and safety" (68.9%). All psychiatrists and almost half of the nurses (45%) said they did not feel the same when they used seclusion. In their opinion, seclusion entailed a less painful experience because of its therapeutic properties. More than half of the caregivers thought that there were alternatives to restraint: the strengthening of containing function in the hours before the use of restraint; the use of seclusion at the time of the decision to restrain. They identified contexts (80%) encouraging the use of restraints, not only related to the patient, the lack of resources but also institutional contexts, in particular conflicts or divisions in the health care team.The misunderstanding of the patient led us to wonder about the quality of the information he/she received: it was sometimes too formal and did not take into account the uniqueness of the patient. The frustration of caregivers could concern the lack of resources but also be directed towards a patient or caregiver. In addition, there were often cleavages between doctors and nurses that stemmed from a misunderstanding, also with rivalries and power struggles. From the literature and caregivers' reflections we identified three prospects to reduce the use of restraint and modify feelings of caregivers: 1) develop better crisis management upstream through increasing resources and improving training; 2) promote patients support in using ethical principles of autonomy and beneficence by showing them solicitude, inviting them to tell themselves and helping them to regain their own experience; 3) develop an afterthought in setting up institutional reflection time by restoring a central role in clinical team meetings in psychiatry, possibly supplemented by supervision, but also through regional ethical spaces.In our investigation, we found that caregivers had a predominantly negative experience with frustration, anger and a lack of feeling. Among caregivers we also identified awareness of ethical issues that may be for the first time for a change.

Case Studies in Public-Sector Leadership: Addressing the Problem of Appointment Nonadherence With a Plan for a Walk-In Clinic

Introduction by the column editors: This column is based on the use of an electronic mailing list (e-list) to generate a collaborative problem-solving process. Dr. Runnels asked e-list members of the American Association of Community Psychiatrists for suggestions regarding the establishment of a walk-in program for patients who regularly miss scheduled appointments. Readers are invited to submit suggestions for e-list discussions of management problems to column editors JulesM. Ranz,M.D., at jmr1@columbia.edu, or Susan M. Deakins,M.D., at smd3@columbia.edu.

College Student Utilization of a Comprehensive Psychiatric Emergency Program

The authors sought to identify college students at risk for experiencing a mental health crisis that warranted a psychiatric evaluation at a hospital and/or a psychiatric hospitalization. A retrospective chart review of college students evaluated at a comprehensive psychiatric emergency program during a 1‐year period was conducted. Demographic variables, mental health treatment history, diagnosis, and hospital discharge plans were found to predict those students likely to be hospitalized and those likely to have positive discharge outcomes.

Practicing Emergency Psychiatry Requires Different Way of Thinking

Practicing Emergency Psychiatry Requires Different Way of Thinking

Suicidal and Homicidal Behaviors Related to Dextromethorphan Abuse in a Middle-Aged Woman

Over-the-counter medications available without prescriptions are generally viewed safe for public consumption. However, when used in excess, these medications can lead to adverse consequences. There are multiple over-the-counter medications that have potential for abuse, and dextromethorphan is one such drug. We describe a case of a middle-aged woman who presented to the psychiatric emergency service after recent use of excessive amounts of dextromethorphan. The patient had developed severe psychotic symptoms and had attempted to kill both herself and her relative. This case highlights the importance of careful reviewing of both prescribed and nonprescribed medications that are being used by patients, especially in the emergency care setting.

Clinical features of inpatients with methamphetamine-induced psychosis

Background: An epidemic of methamphetamine use has begun in Iran in recent years and psychiatric emergency services are overloaded with patients with methamphetamine-induced psychosis (MIP).Aims: To define the clinical features of inpatients with MIP in a psychiatric hospital.Method: The files of all MIP patients admitted to Iran Psychiatric Hospital located in Tehran from April 2008 to April 2010 were assessed. Data related to psychotic episode, substance use, previous psychiatric history and demographic data of 111 MIP patients were extracted and analyzed using descriptive statistical methods.Results: The most prevalent psychotic symptoms were persecutory delusion (82%), auditory hallucination (70.3%), reference delusion (57.7%), visual hallucination (44.1%), grandiosity delusion (39.6%) and jealousy delusion (26.1%). The mean duration of admission and psychotic episode was 21.43 and 17.37 days, respectively. In seven cases (8.75%), symptoms continued for more than one month.Conclusion: Frequency of psychotic symptoms in this study is relatively similar to previous studies. However, some clinical determinants such as latency of psychosis from first use and the course of psychosis are more similar to the first epidemic of methamphetamine in Japan than to more recent epidemics; which could be due to the short history of methamphetamine use in Iran.

1898 – Psychomotor agitation in a psychiatric emergency service

Psychomotor agitation is a relatively frequent condition in Psychiatric Emergency Services. It consists in excessive motor activity and without purpose, with high tension and inability to maintain attention. It carries the risk of compromising the physical integrity of the patient himself or others, usually accompanied by hostility and destructive and / or aggressive behaviors. The authors intend to describe the epidemiological characteristics and the approach of agitated patients in a Psychiatric Emergency Service. It was randomly selected a sample of 52 patients who attended the Metropolitan Psychiatric Emergency Service at Centro Hospitalar São João - Oporto for episode of moderate to severe psychomotor agitation, from January 2012 to August 2012. The authors proceeded to retrospective data collection, including gender, age, diagnosis, the need of physical restraint, the psychotropic therapy instituted and the medical orientation of the patients. In a sample where the average age of patients is 39.7 years and in which 54% are women, the most common diagnoses were psychosis and manic episodes. Physical restraint was required in 17% of patients and 48% accepted oral treatment. Diazepam and olanzapine were the most used drugs orally and haloperidol was the most frequent intramuscular / intravenous treatment. Hospitalization was required in 73% patients. With the development of new psychotropic drugs, including benzodiazepines and antipsychotics, the need of physical restraint decreased. In agitated patients, immediate action is essential to enable effective and rapid control of symptoms, as most situations are serious and require hospitalization.

1353 – One thousand consecutive attendees of a nigerian psychiatric emergency service: clinical and socio-demographic profile

The Psychiatric Emergency service occupies a strategic position where crucial interventions can be initiated and coordinated in linkage with other services in the mental health network. However, there is dearth of information on users of psychiatric emergency in Nigeria and sub-Saharan Africa. To determine the clinical and socio-demographic characteristics, pattern of presentation and disposal of patients attending a Nigerian psychiatric emergency unit. One thousand Patients consecutively presenting to the emergency unit of the Federal Neuro-Psychiatric Hospital Yaba, Lagos, Nigeria from January 2012 were prospectively assessed. Following a comprehensive psychiatric evaluation, clinical, socio-demographic and other relevant data regarding their presentation and disposition were recorded into a pro-forma and subjected to statistical analysis. The majority were females (54.7%), single (65.6%), and unemployed (62.9%), with a mean age of 36.4 (± 14.7) years. Less than two-thirds (62.0%) were new patients. Only 10.8% of the new patients were formally referred to our facility. The most common diagnoses were schizophrenia (34.3%), depression (16.5%) and substance use disorders (11.4%). The patients were predominantly (89.4%) managed as out-patients. The emergency room is a major port of entry into mental health care and could be prone to over-subscription by patients with non-acute problems, especially when alternatives are not readily accessible. Multipronged interventions, including community based care with relevant linkages, may facilitate appropriate utilization of mental health services and reduce the potential for overcrowding of the psychiatric emergency room.