Psychiatric Emergency Room Patients Research Articles

Updated Developments in Fentanyl Use among Psychiatric Emergency Room Patients

Updated Developments in Fentanyl Use among Psychiatric Emergency Room Patients

Transition to suicide ideation and attempt among emergency room patients.

Suicidal thoughts and behaviours (STB) represent a persistent and serious public health problem, and suicide is among the leading causes of death worldwide. We focus on predictors of transition rates and time courses through the STB spectrum among psychiatric emergency room (PER) patients. We aimed to investigate (a) whether currently suicidal patients had prior referrals to the PER, (b) for which reason they were previously referred to the PER and (c) the timing of this referral. We performed a retrospective study spanning 20 years with 24 815 PER referrals. Descriptive statistics of patients' sociodemographic and clinical characteristics are provided and expressed as weighted proportions and means. Logistic regression was used to identify risk profiles of patients who had a higher chance of being referred for reasons of STB given their PER history. Multiple imputation and data weighting techniques were implemented. STB among PER patients was persistent and led to repeated referrals (up to five times more likely), often within a short period (18% <1 month). Those previously referred for ideation/plan had 66% higher risk of making the transition to suicide attempt, with 25% making this transition within a month after previous referral. This is similar to the transition from depressed mood to suicide ideation/plan. STBs in PER patients are persistent and lead to repeated referrals, often within a short period, including transitions to more severe forms of STB.

Rapid tranquilization in a psychiatric emergency room: A naturalistic cohort study in 12 h

The purpose of this study was to conduct a naturalistic assessment of the efficacy of four distinct fast tranquilization techniques (intramuscular haloperidol, midazolam, haloperidol plus promethazine, or haloperidol plus midazolam) over a period of 12 h. The sample included 1603 people who were psychiatric emergency room patients at Hospital Geral de Palmas in Brazil between January 2018 and June 2022. The primary outcome was the number and proportion of patients who achieved the ideal response of the rapid tranquilization concept: tranquil without sedation in all assessments (measure by BARS scale), without restraint, without additional medication and without side effects. The secondary outcomes were mild agitation, tranquil or asleep over 12 h, the need for additional medication, use of physical restraints, and side effects. Among all patients, the proportion of rapid tranquilization over 12 h was 14.1% besides (32.9% for haloperidol, 29.2% for midazolam, 4.1% for haloperidol plus promethazine, and 5.4% for haloperidol plus midazolam) there is response some time in 97%. Logistic regression assessed the rapid tranquilization concept with to haloperidol as parameter: midazolam Exp(B) = 0.718 (95% CI 0.362–1.421), p = 0.341, had no difference; haloperidol plus promethazine Exp(B) = 0.011 (95% CI 0.004–0.026), p < 0.001] and haloperidol plus midazolam Exp(B) = 0.019 (95% CI 0.07–0.050) p < 0.001] had higher chance to fail. Secondary outcomes are described in manuscript. Data suggest that the use of monotherapy should be encouraged, and the use of associations does not produce better results to reach rapid tranquilization over 12 h.

Brief Report: Rates of Fentanyl Use Among Psychiatric Emergency Room Patients.

Opioid overdose-related deaths increased from approximately 18 000 deaths in 2007 to 46 802 deaths in 2018. Fentanyl is primarily responsible for the increase in opioid overdose deaths from 2011 through 2017. The primary aim of this study is to determine the rates of fentanyl in the urine drug screens of all patients who presented to the psychiatric emergency room at VA Connecticut, over 7 months in 2018. Data were collected for all patient presentations between June 2018 and December 2018. There were 746 total patient presentations, with 497 being unique. Collected data included basic demographic information, psychiatric diagnosis, and urine drug screen for various illicit substances, including fentanyl. Over 15% of patients screened positive for fentanyl. Patients who tested positive for fentanyl were further classified based on positive urine drug screening results for other opioids, cocaine, or both. Twenty percent of patients who screened positive for fentanyl and cocaine tested negative for other opioids. This category suggests that some veterans might be consuming fentanyl with cocaine. Fentanyl was found at a high rate, even in the absence of other opioids, which suggests that some veterans might be consuming fentanyl with cocaine. Consequently, harm reduction strategies should be broadened to include all patients at risk of fentanyl overdose, including patients who use substances (eg, cocaine) that are potentially adulterated with fentanyl. This study is the first one of its kind that looked at rates of fentanyl use in all presentations to a psychiatric emergency room. While it is well-known that fentanyl is highly prevalent, these findings extend the current state of knowledge by replication in a psychiatric emergency population. (Am J Addict 2021;30:92-95).

Weather conditions influence the number of psychiatric emergency room patients.

The specific impact of weather factors on psychiatric disorders has been investigated only in few studies with inconsistent results. We hypothesized that meteorological conditions influence the number of cases presenting in a psychiatric emergency room as a measure of mental health conditions. We analyzed the number of patients consulting the emergency room (ER) of a psychiatric hospital in Berlin, Germany, between January 1, 2008, and December 31, 2014. A total of N = 22,672 cases were treated in the ER over the study period. Meteorological data were obtained from a publicly available data base. Due to collinearity among the meteorological variables, we performed a principal component (PC) analysis. Association of PCs with the daily number of patients was analyzed with autoregressive integrated moving average model. Delayed effects were investigated using Granger causal modeling. Daily number of patients in the ER was significantly higher in spring and summer compared to fall and winter (p < 0.001). Three PCs explained 76.8% percent of the variance with PC1 loading mostly on temperature, PC2 on cloudiness and low pressure, and PC3 on windiness. PC1 and PC2 showed strong association with number of patients in the emergency room (p < 0.010) indicating higher patient numbers on warmer and on cloudy days. Further, PC1, PC2, and PC3 predicted the number of patients presenting in the emergency room for up to 7days (p < 0.050). A secondary analysis revealed that the effect of temperature on number of patients was mostly due to lower patient numbers on cold days. Although replication of our findings is required, our results suggest that weather influences the number of psychiatric patients consulting the emergency room. In particular, our data indicate lower patient numbers during very cold temperatures.

What is commonly missed in the suicidal risk assessments in the emergency room?

IntroductionSuicidal behaviour remains the most common reason for presentation to the emergency rooms. In spite of identifiable risk factors, suicide remains essentially unpredictable by current tools and assessments. Moreover, some factors may not be included consistently in the suicidal risk assessments in the emergency room by either emergency medicine physicians or psychiatrists.MethodStep 1 involved the administration of a survey on the importance of suicide predictors for assessment between psychiatry and emergency medicine specialties. In step 2 a chart review of psychiatric emergency room patients in Kingston, Canada was conducted to determine suicide predictor documentation rates. In step 3, based on the result of the first 2 steps a suicide risk assessment tool (Suicide RAP [Risk Assessment Prompt]) was developed and presented to both teams. A second patient chart review was conducted to determine the effectiveness of the educational intervention and suicide RAP in suicide risk assessment.ResultsSignificant differences were found in the rating of importance and the documentation rates of suicide predictors between the two specialties. Several predictors deemed important, have low documentation rates. Thirty of the suicide predictors showed increased rates of documentation after the educational intervention and the presentation of the suicide RAP.ConclusionThough a surfeit of information regarding patient risk factors for suicide is available, clinicians and mental health professionals face difficulties in integrating and applying this information to individuals. Based on the result of this study suicide RAP and educational intervention could be helpful in improving the suicidal risk assessment.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Assessing Suicide Risk: What is Commonly Missed in the Emergency Room?

Although risk assessment for suicide has been extensively studied, it is still an inexact process. The current study determined how busy emergency clinicians actually assessed and documented suicide risk, while also examining the differences between psychiatric and emergency medicine opinions on the importance of various suicide predictors. Phase 1 of the study involved the administration of a survey on the relative importance of various suicide predictors for the specialties of psychiatry and emergency medicine. In phase 2 of the study, a chart review of psychiatric emergency room patients was conducted to determine the actual documentation rates of the suicide predictors. Several predictors that were deemed to be important, including suicidal plan, intent for suicide, having means available for suicide, and practicing suicide (taking different steps leading up to suicide but not actually attempting suicide), had low documentation rates. Medical specialties have different opinions on the importance of various suicide predictors. Also, some predictors deemed important had low documentation rates. Educational interventions and simple assessment tools may help to increase documentation rates of several suicide predictors in busy clinical settings.

Mania following use of ibogaine: A case series

Ibogaine is a naturally occurring hallucinogen with postulated anti-addictive qualities. While illegal domestically, a growing number of individuals have sought it out for treatment of opiate dependence, primarily in poorly regulated overseas clinics. Existing serious adverse events include cardiac and vestibular toxicity, though ours is the first report of mania stemming from its use. To report on a case series of psychiatric emergency room patients whose unregulated use of ibogaine resulted in mania in three patients with no prior diagnosis of bipolar illness. Review and summarize charts of three cases. Relevant literature was also reviewed for discussion. Two cases of reported ibogaine ingestion for self-treatment of addictions, and one for psycho-spiritual experimentation resulted in symptoms consistent with mania. No prior reports of mania were found in the literature, and the literature suggests growing popularity of ibogaine's use. The three cases presented demonstrate a temporal association between ibogaine ingestion and subsequent development of mania. In light of these cases, clinicians faced with a new onset mania may benefit from careful substance use and treatment history, specifically regarding opiates. In the vulnerable and often desperate addiction population, in particular, the number of patients seeking this treatment appears to be growing. We advise clinicians to be prepared for discussing the safety, efficacy, and paucity of good data regarding ibogaine with patients who may be considering its use. (Am J Addict 2015;24:203-205).

Equitable care of psychiatric emergency room patients: it does take a village.

Equitable care of psychiatric emergency room patients: it does take a village.

P-1411 - Suicidal behavior in psychiatric emergency room patients

Portugal consistently presents lower suicide rates when compared with other non-Mediterranean European countries (< 10 suicides/100000 habitants). During the 90's the average annual incidence of suicidal behavior (SB) was 20 times greater than completed suicide. Since this is a common cause of admission to the emergency room (ER) and given that it has a major impact on society and patient's health, it's important to recognize specific groups of patients at risk. Study SB prevalence and the characteristics of those patients admitted to the psychiatric ER at Coimbra University Hospitals (HUC). We retrospectively analyzed clinical files relative to patients admitted to the psychiatric emergency between January and June 2010 and explored data concerning those who presented some form of SB. SB was present in 12,12% of the 4537 patients who were admitted to the psychiatric emergency at HUC, during the first 6 months of 2010. 74% were female. The mean age was 38 (min 13, max 90 years). There were considerable differences between men and women in some socio-demographic variables, such as marital status and profession. There were also differences concerning the diagnoses. While adjustment and depressive disorders were the most common diagnoses in both sexes, alcohol and drug dependence were an important co-morbidity in man with SB. There are important subgroups of patients in risk of SB, namely women and alcoholic and drug dependent males. It is important to target these subgroups in order to establish adequate preventing measures.

Lunar phase cycle and psychiatric hospital emergency visits, inpatient admissions and aggressive behavior

Introduction We examined the correlation between lunar cycles and the number of psychiatric emergency visits, patients’ gender, aggressive behavior, need for inpatient admission, legal referral and need for involuntary chemical restraint in a period of one calendar year. Method Charts of all psychiatric emergency room patients were reviewed retrospectively. Arabic calendar lunar months were divided based on three different models: Two 15 days sections, three 10 days, and six 5 days parts in the third model. Results 5431 patients were seen in the psychiatric emergency service (PES) during a one year period. We did not find a relationship between the visit time (day or night), gender, and legal referral in relation to moon cycles. A higher number of visits during full moon period which was not statistically significant ( P > 0.05) was found. Highest frequency of inpatient admissions was discovered in the first and last parts of the three part model and in the first and last segments of the six part model followed by second and fifth parts ( P-values: 0.000). Conclusion This study revealed a slight increase in number of visits to psychiatric emergency room during full moon periods. In addition a highly significant increase in the severity of illness and aggressive behaviors and agitation in the beginning and end of the moon cycles were noticed. Some of the underlying possible causes such as changes in intra/extracellular fluids, neural and endocrine cell functions, hemodynamic and biological responses and changes in social dynamics and support are discussed.

Perpetration of Violence, Violent Victimization, and Severe Mental Illness: Balancing Public Health Concerns

Perpetration of Violence, Violent Victimization, and Severe Mental Illness: Balancing Public Health Concerns

Child abuse: the fundamental issue in forensic clinical practice.

The practice of forensic psychology and psychiatry has made tremendous advances in the past 20 years. We have moved from a field based solely on vague, subjective opinion, devoid of any support in objective research, to a plethora of well-established research instruments and a vast body of well-founded research studies. Recently, however, some of our colleagues have begun to question whether we have possibly embraced our research findings with too much confidence and enthusiasm (Rogers, 2000; Zonana, 2000). Our field has become almost exclusively devoted to assessment, offering little help to those of us who are charged with the treatment of forensic clients in settings such as prisons, forensic state hospitals, parole outpatient clinics, and conditional release programs.Many clinicians in such settings feel that they cannot really be expected to provide meaningful or effective therapy for their clients. During the same 20 years, there has been a veritable explosion in the field of child abuse research and treatment. With few exceptions (e.g., Gilligan, 1996; Lisak, 1997), there seems to be little communication between these two fields. This is surprising in light of studies on the prevalence of child abuse histories among various populations. Based on the findings of a number of studies (Briere, 1992), about 15% of the general population is thought to have experienced childhood physical abuse. The prevalence rates for childhood sexual abuse are somewhat higher, estimated at 20% to 30% for females (Finkelhor, Hotaling, Lewis, & Smith, 1989; Russell, 1986) and 10% to 15% for males (Finkelhor et al., 1989). These rates have been found to be somewhat higher among psychiatric outpatients and psychiatric emergency roompatients, and are even higher among forensic populations. Noting that most people who have been abused do not become violent, Pincus (2001) observes, “Yet a large number of formerly abused people do become violent and dangerous to society, and there is an undeniable direct link between the experience of abuse and later violence” (p.28). During his tenure as Los Angeles County District Attorney, I heard Gil Garcetti state in a radio interview that 95% of those on death row in California were abused as children. James

Suicidal Behavior in Psychiatric Emergency Room Patients

Psychiatric emergency room (ER) patients are thought to be at increased risk of suicide. The prevalence and characteristics of suicidal behavior in a recent sample of patients who came to the ER for psychiatric evaluation were examined. Charts of 311 consecutive psychiatric ER patients were reviewed. Suicidal behavior was considered present if current suicidal ideation or attempts within 24 hours of or during the emergency evaluation were noted in the chart. Suicidal behavior was present in 38% of the psychiatric ER patients. Younger age, white race, affective disorders in female patients, and substance abuse disorders in male patients were features of the suicidal group. Sex of the patient was not associated with suicidal behavior. Suicidal behavior is prevalent in the psychiatric ER. Effective suicide prevention in this setting will hinge on finding more specific risk factors.

Suicidal Behavior in Psychiatric Emergency Room Patients

Suicidal Behavior in Psychiatric Emergency Room Patients

Aggression and recent substance abuse: Absence of association in psychiatric emergency room patients

Substance abuse has been linked to aggression in community and psychiatric samples. A retrospective chart review in 311 consecutive psychiatric emergency room patients was conducted to assess the association of substance abuse and aggression in an acute psychiatric setting. Various indices of substance abuse, including positive urine toxicology for alcohol, cocaine, and/or cannabis, were not associated with aggressive behavior. Patients with positive toxicology for cocaine were less frequently aggressive than cocaine-negative patients. Among aggressive patients, the presence of psychotic symptoms was the most important factor associated with admission. These findings suggest that aggression is not a common acute manifestation of recent substance abuse in psychiatric emergency room patients. Selection factors in this population and the specifics of an acute psychiatric setting may obscure the association, if any. Acute psychosis seems to have a more important role in this setting. Future studies should focus on the prevention and early treatment of aggression in psychotic emergency room patients.

Diagnostic Stability of Schizophrenia in Psychiatric Emergency Room Patients

Diagnostic Stability of Schizophrenia in Psychiatric Emergency Room Patients

Who brings patients to the psychiatric emergency room?: Psychosocial and psychiatric correlates

In a sample of 311 consecutive psychiatric emergency room patients, 133 (43%) were accompanied by relatives, friends, or others, 113 (36%) came with the police, and 65 (21%) came by themselves. There were more males in the group brought in by police or who came by themselves than in the group accompanied by family or others. Aggression was the presenting problem in about 40% of police referrals. Half the aggressive patients who were brought in by the police were diagnosed with psychotic disorders. Poor social functioning was found in patients who came with police and by themselves, this finding was more pronounced in males. High rates of substance abuse, as suggested by positive toxicology, were found in police referrals and patients who came by themselves. This was mostly due to alcohol in males and cocaine in females. Findings indicate that gender, diagnosis, and psychosocial status contribute independently to who brings patients to the psychiatric emergency room. It is suggested that this information is clinically useful for diagnostic assessment and management. Clinical and research implications are discussed.

Diagnostic stability of schizophrenia in psychiatric emergency room patients.

Diagnoses obtained from the hospital computer system were compared at two consecutive visits in 286 psychiatric emergency room patients within a 7-month period. Diagnostic agreement of schizophrenia and changes from and to schizophrenia were examined. There was moderate stability for a schizophrenic diagnosis in patients at two consecutive visits (kappa 0.5). schizophrenia was a more stable diagnosis in males (kappa 0.6) than females (0.4). Underdiagnosis of schizophrenia in females may be due to initial diagnostic confusion with affective illnesses. Further studies are needed in other settings to assess if underdiagnosis is associated with undertreatment of schizophrenia in females.

Lifetime victimization history, demographics, and clinical status in female psychiatric emergency room patients.

Studies on the impacts of violence often overlook the moderating role of social or demographic variables and the confounding effects of different victimization experiences on the same individual. In the present study, 93 adult women presenting to an urban psychiatric emergency room were interviewed regarding their lifetime victimization history, and their charts were examined for relevant demographic and psychiatric variables. Self-reported childhood sexual and physical abuse were common in this sample (53% and 42%, respectively). Adult physical assaults outside of a relationship were described by 29% of patients, 37% reported adult sexual assaults or rapes, and 42% stated that they had experienced one or more physical assaults within an adult relationship. Childhood and adult victimization experiences were intercorrelated and were associated with certain sociodemographic variables. Logistic regression analyses indicated that both child abuse and adult assaults were uniquely associated with psychiatric difficulties, even after controlling for relevant background variables. Childhood sexual abuse was the most powerful predictor of later psychiatric symptoms and disorders.