Psychiatric Emergency Service Research Articles

Irritability in an open-door pediatric psychiatric emergency service in a middle-income country

BackgroundIrritability is a main reason for referral of a child to a pediatric emergency. Few psychiatric services are dedicated to care for children and adolescents in middle income countries. Thus, there is not a clear picture about the real needs of an emergency unit to optimize the service's demands. This study aims to describe a sociodemographic profile of children and adolescents in a psychiatric emergency service due to complaints of irritability. MethodsIn total, 2,255 medical records were reviewed from patients referred within a year at an emergency department of a mental health service for children and adolescents. Patients with and without irritability were compared in terms of sociodemographic features, psychiatric complaints and associated somatic and psychiatric disorders. ResultsAbout 30% of youths attending at this service had irritability. Most were boys (67%) with an average age of 12.6 years (±3.9). Irritability was associated with a diagnosis of mood disorder, attention deficit hyperactivity disorder and oppositional defiant disorder. LimitationsThere are concerns about the setting in which data was collected, since it might have some time restrictions and data imprecision. ConclusionIrritability was a frequent complaint taking children and adolescents to the emergency department. This symptom co-occurs with several psychiatric disorders. These findings support the trans-nosographic view of irritability, in particular its co-occurrence with neurodevelopmental disorders.

More Than Suicide: Mortality After Emergency Psychiatric Care and Implications for Practice.

Emergency departments (EDs) provide vital mental health services. ED patients with behavioral health presentations, particularly suicidal ideation, are at increased risk of death by suicide, medical illness, trauma, or overdose. Causes of death for patients who receive specialty emergency psychiatric services remain undescribed. We describe the incidence and cause of death after care in a psychiatric emergency service (PES). Mortality data were obtained for all adult patients treated in a safety net ED from April 2016 to June 2020. Causes of death were categorized as medical, external (accidents, overdoses, and homicide), or suicide and compared between PES patients and ED patients who were not treated in the PES. Correlates of mortality were described for PES patients. We analyzed 164,422 encounters including 6063 PES visits. Mortality in the 30 days after discharge was 0.3% among PES patients and 0.6% among medical ED patients. At both 30 and 365 days, PES patients were more likely to die by suicide than medical ED patients, and ED patients were more likely to die by medical causes. Among PES patients who died within 365 days, 46% died by medical causes, 32% by external causes, and 23% by suicide. In multivariable analyses, age was associated with all-cause, medical, and external mortality after a PES visit; opioid and stimulant use disorders were associated with all-cause and external mortality. Most patients who die after receiving emergency psychiatric care die by medical and external causes such as accidents, overdose, and homicide. Patients who are older and have opioid or stimulant use disorders are at higher risk of nonsuicide mortality. We propose interventions to reimagine emergency psychiatric care and address nonsuicide mortality among psychiatric patients treated in emergency and crisis settings.

The effectiveness of intensive home treatment as a substitute for hospital admission in acute psychiatric crisis resolution in the Netherlands: a two-centre Zelen double-consent randomised controlled trial

BackgroundAlthough de-institutionalisation has been underway for decades, admission to hospital followed by low-intensity outpatient care remains the usual treatment for patients with an acute psychiatric crisis. Intensive home treatment has been developed for patients in a severe psychiatric crisis as an alternative to inpatient care. This study aimed to evaluate the potential of intensive home treatment to reduce bed-days and its clinical effectiveness compared with treatment as usual. MethodsWe did a two-armed, two-centre, open-label, Zelen, double-consent, pragmatic randomised controlled trial. Patients aged 18–65 years were recruited at the psychiatric emergency service and psychiatric emergency wards of the two major mental health institutions (Arkin and GGZ inGeest) in Amsterdam, the Netherlands. Patients diagnosed with at least one DSM-IV-TR or DSM-5 disorder and in a psychiatric crisis and for whom psychiatrists had indicated or completed a clinical admission could be included. Trained psychiatric emergency service and hospital professionals did the automated web-based pre-randomisation procedure upon first contact with the patient. A seeded pseudo-random number generator allocated patients (2:1) to intensive home treatment or treatment as usual. Informed consent was obtained after randomisation as soon as the patient was mentally capable within 14 days. Due to the nature of this study, patients and professionals were not masked to treatment. Intensive home treatment was tailored to the nature of the crisis and goals of patients and relatives, and developed in collaboration with them and a multidisciplinary professional team. All main analyses were intention-to-treat, and the primary outcome was the total number of admission days 12 months after randomisation. To investigate the effect of treatment conditions on the outcome measures, linear mixed modelling analyses using restricted maximum likelihood estimation were done. This trial was prospectively registered with Trialregister.nl, NL-6020 (NTR-6151). FindingsBetween Nov 15, 2016, and Oct 15, 2018, 246 patients were included in the study (183 patients with intensive home treatment vs 63 patients with treatment as usual). 135 women (55%) and 111 men (45%) were included, with a mean age of 41·01 years (range 18–65; SD 12·68). 114 participants (46%) were born in the Netherlands and 85 (35%) elsewhere (missing data on 47 [19%] participants). Ethnicity data were not available. After 12 months, the mean number of admission days in the intensive home treatment condition was 42·47 (SD 53·92) versus 67·02 (SD 79·03) for treatment as usual, a reduction of 24·55 days (SD 10·73) or 36·6% (p=0·033). 26 adverse events were registered, 23 (89%) of which were suicide attempts. The number of patients with a reported adverse event did not differ significantly between the groups (15 [8%] in the intensive home treatment group vs five [8%] in the treatment as usual group; p=0·950). Five patients died by suicide (three [2%] in the intensive home treatment group vs two [3%] in the treatment as usual group; p=0·610). No treatment-related deaths occurred. InterpretationIntensive home treatment is a safe and effective partial substitute for conventional psychiatric crisis care that led to a reduction in admission days, causing patients to stay longer in their social environment, with similar clinical effects, patient satisfaction and adverse events. FundingDe Stichting tot Steun Vereniging voor Christelijke Verzorging van Geestes-en Zenuwzieken.

Attention deficit hyperactivity disorder in adults who present with self-harm: a comparative 6-month follow-up study

BackgroundADHD is common in psychiatric populations. This study aimed to compare clinical characteristics in adults with and without ADHD who presented with self-harm, and to compare later risk of suicidal behaviour within 6 months.MethodsEight hundred four adults presented with self-harm (with and without suicidal intent) at psychiatric emergency services at three Swedish hospitals. Persons with a discharge ICD-10 diagnosis F90.0-F90.9 or a prescription for ADHD medication were considered to have ADHD (n = 93). Medical records were reviewed for evidence of subsequent suicide attempts (SA) within 6 months; suicides were identified by national register.ResultsRecent relationship problems were more prevalent in the ADHD group. While the index episodes of those with ADHD were more often non-suicidal, and actual SAs more often rated as impulsive, medical lethality at presentation did not differ in attempters with and without ADHD. Subsequent SAs (fatal or non-fatal) were observed in 29% of the ADHD group and 20% in all others (P = .005). A logistic regression model showed elevated risk of suicidal behaviour during follow-up in the ADHD group (OR = 1.70, CI 1.05–2.76), although a final regression model suggested that this association was partly explained by age and comorbid emotionally unstable personality disorder.ConclusionsFindings highlight the need for clinicians to take self-harm seriously in adults with ADHD.

Emergency Psychiatry before and during COVID-19 pandemia

IntroductionThe COVID-19 pandemic had a significant impact worldwide. Consultations in the Emergency Service of the Hospital Clínic of Barcelona varied in terms of reasons for consultations, psychopathology, and other aspects, before and after the pandemic.ObjectivesTo examine changes in the profile of patients admitted before and during the COVID-19 pandemic to our Psychiatric Emergency Service.MethodsAll children, adolescent and adult psychiatric inpatients admitted from December 4th 2019 to March 31st 2021 to the Psychiatric Emergency Service of Hospital Clínic of Barcelona, Spain, were retrospectively included for analysis and divided into two groups –groups 1 or 2- including the first one all patients who attended before lockdown and the second group those who attended during the pandemic.ResultsA total of 1991 patients were included -1224 in the first group and 767 in the second group. The majority of patients were male (52.08%), with a mean age of 41.21 years (SD 16.53). A proportion significantly higher of men was found in the second group (p<0.05). The proportion of patients consulting with substance use disorders was significantly higher in the second group (p<0.05). Patients from the second group presented a significantly higher proportion of admissions in an acute psychiatric ward (p<0.05), and also a significantly higher proportion of consultations of patients with dementia (p<0.05).ConclusionsThe COVID-19 pandemic lead to a significant reduction in the overall consultations, with a higher proportion of severe cases. The lack of availability of caregivers and telework might have influenced the increase in consultations of patients with dementia.DisclosureAG has received travel and financial support from Janssen, Otsuka-Lundbeck and Angelini, and research support from Instituto de Salud Carlos III, and declares no support related with the subject of this presentation.

Early Community based Ayu-Emergency Intervention in Psychiatric Emergencies: A Community Based Participatory Research

IntroductionPsychiatry emergencies in India is major challenge for emergency service providers due to rapid growth of various behavioural, higher morbidity and mortality rate. Despite, psychiatry conditions are neglected area related to stigma, share, lack of awareness, and superstitious beliefs. There is an urgent need for specialist psychiatric emergency services, which can fill the huge gap between policymakers and health service providers joined together.ObjectivesPresent feasibility study has been undertaken to evaluate the safety and efficacy of combined emergency and Ayurveda medicine management of psychiatric emergencies in community-based settings.Methods Ayu-Emergency Care project was developed in partnership with policy makers, researchers and health care providers, a collaborative platform of emergency medicine and Ayurveda medicine (Indian Traditional Medicine) for developing whole-system perspective, where providers work in a coordinated and joined-up way. Twenty trained care providers in psychiatry emergency and Ayurveda management worked in partnership with community-based organisation.ResultsPatients with major clinical difficulties, in the acute phase were treated and managed by Ayu-Emergencypractitioners. Severe Agitation and violence relating to substance abuse, anxiety disorder and psychosis were the most common admission diagnoses. 2-weeks results indicate that Ayurveda intervention can reduce anxiety(p<0.01), aggression (p< 0.001) and agitation (p<0.01) significantly with no side effects reported. Intervention found to be clinically beneficial and cost-efficient alternative to out-of-home placements (i.e., Incarceration, psychiatric hospitalisation).ConclusionsThe study’s findings highlight safety, efficacy and feasibility of intervention. Patients both prefer and seem to benefit from community-based ayu-psychiatric care, and early-intervention community program could be a good model for such care.DisclosureNo significant relationships.

Referral for Intensive Home Treatment or Psychiatric Inpatient Care? A Retrospective, Observational Comparison of Patient and Process Characteristics.

IntroductionIntensive home treatment (IHT) is intended to prevent the (mostly voluntary) admission of mentally ill patients by providing intensive care in their domestic environment. It requires approaches to referral that ensure the delivery of the best possible acute care. Indications for referral may be improved by greater understanding of the clinical profiles of patients referred for IHT and of those referred for inpatient care. As such understanding may also further the development of IHT and innovations within it, we compared the patient and process characteristics associated with IHT referral for those associated with inpatient care.MethodsThis retrospective, observational, explorative study was conducted from 2016 to 2019. Patients aged 18 years and older were assessed by the emergency psychiatric outreach services in the greater Rotterdam area (Netherlands). Anonymized data were used to compare patient and process characteristics between patients referred for IHT and those admitted voluntarily. Patient characteristics included gender, age, cultural background, living situation and main diagnosis. Additional the case mix was measured using the Severity of Psychiatric Illness (SPI) scale. Process characteristics included psychiatric history, the total number of contacts with the emergency psychiatric outreach services, assessments during office hours, place of assessment, referrer, and the reason for referral. Using multiple logistic regression analysis, the patient and process characteristics associated with IHT referral were compared with those associated with voluntary admission.ResultsThe emergency psychiatric outreach services undertook 12,470 assessments: 655 were referred for HT and 2,875 for voluntary admission. Patient characteristics: referral for IHT rather than voluntary admission was associated with higher motivation for treatment and better family involvement. Process characteristics: referral for IHT rather than voluntary admission was associated with assessment by the crisis services within office hours, no mental health treatment at the time of referral, and referral by a family doctor.DiscussionIHT in a specific Dutch setting seems to function as an intensive crisis intervention for a subgroup of patients who are motivated for treatment, have social support, and are not in outpatient treatment. The patient and process characteristics of patients referred for IHT should now be studied in more detail, especially, for having more social support, the role of the family members involved.

A 6-year retrospective review of psychiatric emergency service utilization by school-age children.

To explore utilization patterns and associated clinical factors of school-age children who present to a psychiatric emergency department. This was a 6-year retrospective chart review study of children 5-12years of age who presented to a psychiatric emergency service from July 2012 to June 2018 (n = 1654 patients). Demographic variables, clinical diagnoses, lifetime adverse events (physical abuse, sexual abuse, and bullying), and history of self-harm were documented for each visit. We performed a chi square analysis to identify association between demographic and clinical features with key outcomes. Increased service utilization as defined by inpatient psychiatric admission, recurrent visits, or increased length of stay were found in patients who were adopted, presented with suicidal ideation or self-harm behaviors, had a history of abuse, and had a diagnosis of depression or autism. Trends over the course of the study indicated a significantly increased percentage of patients presenting with suicidal ideation, bullying, and self-harm behaviors. The data add to the limited literature regarding school-age children with a psychiatric emergency. Increased emergency service utilization for certain subgroups of children and trends over the course of the study underscore the need for enhanced treatment options for individuals with certain demographic or clinical features, and increased outpatient, intermediate, and inpatient treatment options, as well as preventative care.

Psychiatric emergency units in Brazil: a cross-sectional study.

This study aimed to identify the infrastructure (e.g., availability, resources, and staff), basic metrics, and problems (e.g., network, overcrowding, resources, and infrastructure) of the psychiatric emergency services in Brazil. This is a cross-sectional study assessing psychiatric services (n=29) listed by the Brazilian Psychiatric Association in 2019. Almost all the units reported 24 h/7-day availability having psychiatrists, nurses, and social workers, with 8.8 (SE=2.2) and 2.8 (SE=0.3) consultations and hospitalizations per day, respectively. Separated room for contention was reported by the minority of the services (38%). The most commonly reported problems were insufficient structure for child/adolescent care (83%), increasing patient demand (72%), housing referral for homeless (72%), excessive prescription demand (69%), short-term room overcrowding (59%), court orders for inpatient treatment (59%), lack of vacancies for inpatients hospitalization (59%), and referral to primary care (56%). Similar to the United States, the Brazilian psychiatric emergency units are decreasing and encompass the shortcomings of the Brazilian mental health care network.

The Impact of SARS-CoV-2 Infection on Youth Mental Health: A Narrative Review.

Background: COVID-19 pandemic has affected the physical health, psychological wellbeing, and mental health of the whole population. Young people are among those most at risk of developing mental health symptoms or disorders related to the pandemic. Purpose: the present narrative review is aimed at providing an updated overview of the current literature concerning the psychological impact of the SARS-CoV-2 infection but also of the COVID-19 outbreak, environmental restriction, and social distancing on mental health outcomes among the youth population aged between 15 and 25 years. Methods: in December 2021, an electronic search on this topic was performed on PubMed. Relevant publications from January 2020 until December 2021 were included. Findings: 53 cross-sectional studies, 26 longitudinal studies, 4 ecological studies, 1 qualitative study, and 1 systematic review were included. We found many methodological limitations in the studies included, especially poor choice of study samples and short follow-ups. Little literature was in support of a strong relationship between SARS-CoV-2 infection and consequences on youth mental health. On the contrary, many studies showed how extraordinary measures to limit the spread of the virus have impacted young people in terms of onset of new mental disorders and symptoms, suicidality, and access to emergency psychiatric services. Depressive and anxiety symptoms and disorders show the greatest increase in incidence, especially in girls and young women. Conclusions: it seems important to pay attention to the mental health of young people in relation to the consequences of the COVID-19 pandemic. However, studies with more robust methodologies and longer follow-ups are needed to establish precise indications for targeted interventions in this context.

Retrospective Analysis of Hospital Records of Patients Admitted to the Emergency Department and Diagnosed with Psychiatric Disorder

Objective: This study aimed to retrospectively assess the hospital records of patients admitted to the emergency department of a training research hospital and diagnosed with a mental/psychiatric disorder. Material-Methods: In our study, medical records with pre-diagnosis of psychiatric disorder were scanned retrospectively in the electronic environment from the applications made to the emergency department of a training and research hospital in a one-year period covering 2017. The data were collected using a form prepared as per the current literature and developments. Using descriptive statistics, socio-demographic and health history characteristics and clinical diagnoses were evaluated. Results: It was determined that 84.04% of all patients that were admitted to the emergency department for mental health reasons were diagnosed with code F41 (other anxiety disorders), that 23.60% were in the 15-24 age group, and that 69.50% were female. The emergency department admission characteristics of the subjects were as follows: 10.60% of all admissions were made in July, 48.20% were made between 16:01-00:00, 5.00% were referred to psychiatric consultation, 93.60% received ambulatory follow-up, and 12.90% were admitted to the emergency department two or more times within one year. Conclusion: The most common diagnosis was “other anxiety disorders” and the majority of the patients were young adults and female. Since emergency departments are among the first places where individuals seek medical care for mental health, we believe that our results will help structure emergency psychiatric services.

Psychiatric Emergencies in Minors: The Impact of Sex and Age.

ObjectiveLittle information is available on young children (age 4–12 years) with mental health problems who are seen by the psychiatric emergency services. We therefore described this population to identify (1) variables that differentiated children from those aged 13 to 18 years who had been referred for psychiatric emergency consultation; and (2) to describe sex differences.MethodWe extracted data for a 9-year period from the records of the mobile psychiatric emergency services in 2 urban areas in the Netherlands. In this period, 79 children aged 4 to 12 years (37.2% girls) and 1695 children aged 12 to 18 years (62.2% girls) had been referred for psychiatric emergency consultation. Demographic and process factors were recorded. Clinical characteristics included diagnostic and statistical manual of mental disorders, 4th edition classifications and the Severity of Psychiatric Illness scale. Logistic regression analyses were used to examine differences between the girls and boys in the 2 age groups.ResultsYoung children aged 4 to 12 years had been involved in 4.5% of all consultations of minors. In contrast with adolescents, a higher percentage of young children seen for emergency consultation were boys, and a lower percentage was admitted to a psychiatric hospital (7.7%). In boys and girls alike, a DSM classification of behavioral disorder was associated with younger age.ConclusionsThe young group of children referred for psychiatric emergency consultation comprised relatively more children with behavioral disorders. Decisions to refer them for urgent psychiatric consultation seemed to be influenced by the suspicion of psychotic symptoms or of danger to themselves or others.

The mental distress of our youth in the context of the COVID-19 pandemic.

Epidemiological evidence from population-based surveys suggest that the psychological well-being of adolescents has been severely affected by the COVID-19 pandemic itself, as well as by the safety measures implemented. The rationale of the study was to investigate the influence of the pandemic on psychiatric emergency service use, psychiatric admissions rates, emotional well-being, suicidality and self-harm behaviour in help-seeking children and adolescents. Retrospective cohort study of electronic patient records before and during the COVID-19 pandemic from the emergency out-patient facility of the department of child and adolescent psychiatry and psychotherapy of the Psychiatric University Hospital Zürich. The frequency of all emergency service contacts from 1 January 2019 to 31 June 2021 were described and the frequency of records compared in half-year intervals. Emotional well-being, behavioural problems, suicidality and self-harm were estimated based on the mental state examination notes of electronic patient records from the 1 March to the 30 April for the years 2019, 2020 and 2021. After an initial decline in emergency contacts at the beginning of the first lockdown, the use of the centralised emergency service increased during the subsequent months and has since stabilised at a significantly higher level than before the pandemic. Comparison of emergency contacts in the first half of 2019 with the first half of 2021 shows that the number of emergency phone contacts nearly doubled, emergency outpatient assessments increased by 40%, emergency bridging interventions increased by 230%, and inpatient admissions of minors to adult psychiatric inpatient units more than doubled because of lack of service capacity in child and adolescent psychiatry. The proportion of adolescents who reported suicidal ideation increased significantly by 15%, from 69% to 84%, and the proportion of adolescents who reported self-harm behaviour increased by 17%, from 31% to 48%. We found a significant increase in psychiatric service use, as well as in reported serious mental health symptoms such as suicidality and self-harm behaviour in help-seeking children and adolescents in the course of the pandemic. The child and adolescent psychiatric healthcare system is overburdened and down-referral of adolescents in need of ongoing therapy is becoming increasingly difficult. We recommend prioritising preventive and therapeutic measures to support the mental health of our children and adolescents alongside the somatic management of the COVID-19 pandemic.

COVID-19 Vaccine Administration and Hesitation Among Psychiatric Emergency Services Patients.

Psychiatric Emergency Services (PES) at Connecticut Department of Veterans Affairs (VACT) began offering the COVID-19 vaccine to eligible veterans in February 2021. From February 10 to March 17, 2021 there were 110 encounters where a veteran was offered the vaccine (96 unique veterans). Of those 96 veterans, 39 (40.6%) were interested in receiving the vaccine. Of those, 23 (60.0%) veterans received the first dose of the Pfizer-BioNTech vaccine and among those, 21 (91.3%) eventually received the second dose. Sixteen veterans were interested but unable to receive the vaccine due to PES-related obstacles. Common themes regarding vaccine hesitancy among this population include vaccine mistrust and concerns about side effects. Offering the vaccine to PES patients allowed VACT to reach a vulnerable subset of veterans who may be at higher risk of contracting the virus and experience worse disease outcomes.

Abstract- Poster

Background:A psychiatric emergency is an acute disturbance of behaviour, thought or mood of a patient which if untreated may lead to harm, either to the individual or to others in the environment. Thus, the definition of a psychiatric emergency differs from other medical emergencies in that the danger of harm to the society is also taken into account. Recent trends shows that there is a increase in substance use in general population and people who attend psychiatric services provided.Aim Of the study:To asses the clinical profile and sociodemographic details of patients presenting to emergency psychiatric services with substance use disorderMethodology:Study site:Institute of Mental health, Madras Medical College, ChennaiStudy designCross sectional studySample size:23Duration:July 2021 to August 2021Results:Majority of the study participants belongs to 31-40 years of age group and 10(43.5%) were doing unskilled work (43.5%).The common reason for consultation is hearing voices 30.4% followed by violent behaviour26.1%The most common diagnosis of study participants is alcohol withdrawal34.8% and 21.7% had perceptual abnormalities.Conclusion:People with substance use disorder seek treatment from emergency psychiatric services. Hence psychoeducation and referring to medical units if needed should be done. Analyzing the reason for consultation and pharmacological management and psychotherapies with follow up would reduce substance use in the patients.

Insomnie et risque suicidaire dans les troubles de la personnalité du groupe B : une étude comparative transversale

Objectif Le taux de mortalité par suicide parmi les personnes souffrant d’un trouble de la personnalité du groupe B (TPB) se situe autour de 20 %. La haute prévalence de comorbidités anxiodépressives ainsi que l’abus de substances majorent ce risque. Selon des études récentes, l’insomnie persistante serait aussi un facteur de risque suicidaire dans ce groupe clinique. Les mécanismes expliquant cette association sont peu connus. Il a été proposé que des facteurs psychopathologiques comme la dysrégulation émotionnelle ou l’impulsivité pourraient agir comme médiateurs dans ce lien entre l’insomnie et le suicide. Afin de bien comprendre la relation insomnie-suicide dans le TPB, il est important d’identifier le rôle des comorbidités. L’étude comporte deux objectifs. Le premier vise à comparer la sévérité des symptômes d’insomnie et le niveau d’impulsivité d’un groupe avec TPB à ceux d’un groupe contrôle, le deuxième tente d’établir les relations entre l’insomnie, l’impulsivité, les comorbidités anxiodépressives, l’abus de substance et le risque suicidaire. Méthode Étude transversale portant sur 138 patients (âge moyen = 33,74 ; 58,7 % femmes) ayant un TPB. Les données de ce groupe, obtenues à partir d’une base de données d’un institut en santé mentale québécois (banque Signature : www.banquesignature.ca) ont été comparées à celles d’un groupe de 125 sujets sains appariés sur l’âge et le sexe et sans historique de trouble mental. C’est à l’admission aux urgences psychiatriques que le diagnostic de TPB a été déterminé à l’aide d’une entrevue diagnostique et que des questionnaires autorapportés mesurant l’anxiété, la dépression, l’impulsivité et l’abus de substances ont été remplis par les participants. Les participants du groupe contrôle se sont rendus au centre Signature afin de compléter ces mêmes questionnaires. Une matrice corrélationnelle et une régression linéaire multiple ont été utilisées pour explorer les relations entre les variables. Résultats Le groupe avec TPB présentait des symptômes d’insomnie plus élevés et des niveaux d’impulsivité supérieurs par rapport au groupe contrôle, à l’exception du temps total de sommeil. Dans le modèle de régression, la satisfaction envers le sommeil, le manque de préméditation, l’urgence positive, la dépression et l’utilisation de substances étaient significativement associés aux scores au Suicidal Behavior Questionnaire-Revised (SBQ-R). Ce modèle expliquait 46,7 % de la variance des scores au SBQ-R. Conclusion Les résultats ont permis de mettre en évidence, pour la première fois, les éléments d’insomnie et d’impulsivité qui distinguent un groupe avec TPB par rapport à un groupe contrôle sain. Cette étude indique que l’insomnie et l’impulsivité pourraient être des facteurs de risque suicidaire dans le TPB, indépendamment des comorbidités et de l’utilisation de substances. De futures études permettront de vérifier la pertinence clinique potentielle de ces éléments de risque pour cette patientèle.

Cops, Clinicians, or Both? Collaborative Approaches to Responding to Behavioral Health Emergencies.

How a community responds to behavioral health emergencies is both a public health issue and social justice issue. Individuals experiencing a behavioral health crisis often receive inadequate care in emergency departments (EDs), boarding for hours or days while waiting for treatment. Such crises also account for a quarter of police shootings and >2 million jail bookings per year. Racism and implicit bias magnify these problems for people of color. Growing support for reform provides an unprecedented opportunity for meaningful change, but solutions to this complex issue will require comprehensive systemic approaches. As communities grapple with behavioral health emergencies, the question is not just whether law enforcement should respond to behavioral health emergencies but how to reduce unnecessary law enforcement contact and, if law enforcement is responding, when, how, and with what support. This policy article reviews best practices for law enforcement crisis responses, outlines the components of a comprehensive continuum-of-crisis care model that provides alternatives to law enforcement involvement and ED use, and offers strategies for collaboration and alignment between law enforcement and clinicians toward common goals. Finally, policy considerations regarding stakeholder engagement, financing, data management, legal statutes, and health equity are presented to assist communities interested in taking steps to build these needed solutions.

Suicide and Self-Harm Outcomes Among Psychiatric Emergency Service Patients Diagnosed As Malingering.

Malingering is a common and challenging clinical presentation in emergency departments (EDs). This study describes characteristics and outcomes among patients diagnosed as malingering in a psychiatric emergency service. Index psychiatric ED encounters were identified for all adult patients seen during a 27-month period. Mortality data were obtained for patients from the state public health authority, and repeat ED visits for self-harm were obtained from the state hospital association. Patients with a diagnosis of malingering were compared with those without a malingering diagnosis using correlative statistics and multivariable analyses. Of 4710 encounters analyzed, 236 (5%) had a malingering diagnosis. No patients diagnosed as malingering died of suicide within 365 days of discharge, compared with 16 (0.4%) nonmalingering patients. Self-harm outcomes were available for 2689 encounters; 129 (5%) had a malingering diagnosis. Malingering was significantly associated with a repeat ED visit for self-harm within 365 days in multivariable analyses (adjusted odds ratio 2.52; 95% confidence interval 1.35-4.70); p < 0.01). No psychiatric emergency service patients diagnosed as malingering died by suicide after discharge. New clinical approaches must balance malingering patients' apparent low suicide risk with their other substantial comorbidities and risk for self-harm.

The Association of Childhood Maltreatment, Sex, and Hair Cortisol Concentrations With Trajectories of Depressive and Anxious Symptoms Among Adult Psychiatric Inpatients.

Depression and anxiety symptoms are commonly observed among clinical populations, especially among women and maltreated individuals. Few investigations have, however, assessed the existence of distinct symptoms trajectories among clinical populations and how these relate to childhood maltreatment, sex differences, and stress physiology indexed by hair cortisol concentrations (HCCs). The current study a) identified distinct depression and anxious trajectories in a sample of psychiatric inpatients followed up prospectively from their admission to a psychiatric emergency service, and b) examined whether HCC, childhood maltreatment, and sex independently and jointly predict these trajectories. Adult inpatients (n = 402; 55% women) were recruited upon admission to psychiatric emergency service (T1) during which HCC (reflecting cortisol secretion for the last 3 months), childhood maltreatment, and depression and anxiety symptoms were assessed. Symptoms were reevaluated when patients were discharged from the hospital (T2), admitted to outpatient clinics (T3), and 12 months later or at the end of outpatient treatment (T4). Three trajectories were identified for depression and anxiety symptoms. Among men, higher HCC predicted higher odds of evincing chronic depressive symptoms compared with a low stable trajectory (odds ratio [OR] = 3.46, 95% confidence interval [CI] = 1.43-8.40). Greater childhood maltreatment among men predicted higher chances of exhibiting chronic anxious symptoms than the low stable (OR = 1.47, 95% CI = 1.07-2.02) and the high decreasing trajectories (OR = 0.70, 95% CI = 0.51-0.95). Opposite findings were noted for women. Childhood maltreatment and HCC should be further investigated as predictors of anxious and depressive trajectories, during which sex-specific associations ought to be considered.

A comparison of aggression between patients with acute schizophrenia and mania presenting to psychiatric emergency services

ObjectiveAggression is common and challenging in psychiatric emergency departments (PED). However, the prevalence of aggression and its correlates in PED patients are not well documented. This study compared the prevalence of aggression between patients with acute schizophrenia and manic episodes. MethodsIn this cross-sectional study, patients at a psychiatric emergency department were assessed with measurements of aggression, psychotic and manic symptoms. ResultsA total of 4,172 patients were included. The prevalence of aggression was 54.8% (95%CI=53.3%-65.2%) in the whole sample, with 48.0% (95%CI=45.8%-50.1%) in patients with an acute schizophrenia episode, and 61.8% (95%CI=59.8%-63.9%) in patients with a manic episode. Multiple logistic regression analysis revealed that, within the acute schizophrenia episode group, male gender (OR=1.47, P<0.01), involuntary admission (OR=3.61, P<0.01) and more severe manic symptoms (OR=1.30, P<0.01) were significantly associated with aggression. Within the manic episode group, living in Beijing (OR=1.51, P<0.01), unemployment (OR=1.34, P=0.03), involuntary admission (OR=7.93, P<0.01), lower education (OR=0.95, P=0.01) and more severe psychotic symptoms (OR=1.05, P<0.01) were significantly associated with aggression. ConclusionIn this study, aggression appeared to be more common among patients with a manic episode than those with an acute schizophrenia episode. Considering the significant risk of aggression on psychiatric emergency care, appropriate and effective management of aggression in this population group need to be developed.