Psychiatric Emergency Service Research Articles

Brazilian Psychiatric Association Consensus on the physical structure and ideal team for psychiatric emergencies services.

An integral part of Brazil's public health system, the psychiatric emergency service (PES) has been instrumental in improving qualified support for crisis situations of mental disorders, equitable, universally accessible, and humanized. The purpose of this article is to present a systematic review and consensus about the physical area and facilities, and ideal team qualified for psychiatric emergencies services on both Brazilian settings. The authors conducted a literature search using electronic databases such as MEDLINE (PubMed), Scielo, the Cochrane Database, and documents from the WHO, the Brazilian Ministry of Health, and others deemed relevant by experts. A total of 6839 manuscripts were found, but only 46 were selected. The analysis of article content summarizes consensus statements using the Delphi method and a series of interactive versions to provide a final report. Changes to PES are evaluated considering various experiences and models. The authors highlighted that The Emergency Care Network (ECN) must be coordinated with qualified management, effective implementation of integration of all health equipment's and units. PES must have adequate infrastructure; qualified staff, including a psychiatrist; sufficient consultation and observational spaces; tools and resources for differential diagnosis; training for all staff members; and communication with the health care network to facilitate referrals following patient discharge are all necessary. These standardized models need to be available to public health managers so that they can guide the installation of new services and adjust the existing ones, always looking for improvement. The authors propose requirements for PES as a model to be passed over.

Gender-specific pathways in mental health crisis in adolescents, from consultation to (in)voluntary admission: a retrospective study

BackgroundA strong increase in mental health emergency consultations and admissions in youths has been reported in recent years. Although empirical evidence is lacking, gender differences in risk of admission may have contributed to this increase. A clearer understanding of the relationship, if any, between gender and various aspects of (in)voluntary care would help in more evidence-based service planning.MethodsWe analysed registry data for 2008–2017 on 3770 outpatient emergencies involving young people aged 12 to 18 years from one urban area in the Netherlands, served by outreaching psychiatric emergency services. These adolescents were seen in multiple locations and received a psychosocial assessment including a questionnaire on the severity of their problems and living conditions. Our aims were to (a) investigate the different locations, previous use of mental health service, DSM classifications, severity items, living conditions and family characteristics involved and (b) identify which of these characteristics in particular contribute to an increased risk of admission.ResultsIn 3770 consultations (concerning 2670 individuals), more girls (58%) were seen than boys. Boys and girls presented mainly with relationship problems, followed by disruptive disorders and internalizing disorders. Diagnostic differences diminished in hospitalisation. More specifically, disruptive disorders were evenly distributed. Suicide risk was rated significantly higher in girls, danger to others significantly higher in boys. More girls than boys had recently been in mental health care prior to admission. Although boys and girls overall did not differ in the severity of their problems, female gender predicted admission more strongly. In both boys and girls severity of problems and lack of involvement of the family significantly predicted admission. Older age and danger to others significantly predicted admission among boys, whereas psychosis, suicidality and poor motivation for treatment predicted admission among girls.ConclusionThere are different pathways for youth admission, which can partly be explained by different psychiatric classifications as well as gender-specific differences with regard to age, suicide risk, danger to others and the influence of motivation for treatment. Finally, for both genders, family desire for hospitalisation is also an important predictor.

Addressing Mental Health Needs in Low- and Middle-Income Countries: The case of São Caetano do Sul, Brazil.

São Caetano do Sul, a city in southeastern Brazil, boasts exemplary social indicators and healthcare services, with a population of 162,763 and a density of 9,736.03 inhabitants/km². Allocating 25% of its budget to healthcare, the city's mental healthcare services adhere to the National Mental Health Policy. Structured services include a CAPS-II, CAPS-AD, outpatient teams, and teams in various locations. Initiatives since 2000 include inaugurating a CAPS-AD in 2006, a psychiatric emergency service in 2010, and a CAPS-II in 2016, relocating CAPS-AD in 2019, and establishing the Cuca Legal Project in 2022. São Caetano do Sul has a Mental Health Risk Classification Protocol to aid clinical decision-making. Developing care lines for various groups, it offers programs like smoking prevention, school psychology, and obesity support. Collaborating with community centers, these facilities serve as teaching environments. The mental health care network focuses on five axes: Communication, Care, Prevention, Management, and Education, with specific proposed actions and competencies. Despite progress, challenges remain. Expanding access, reducing stigma, and implementing robust monitoring are crucial. São Caetano do Sul's experience offers valuable insights for similar urban settings in LMICs developing mental health programs.

Receiving a gift and feeling robbed: a phenomenological study on parents’ experiences of Brief Admissions for teenagers who self-harm at risk for suicide

BackgroundBrief Admission by self-referral is a preventive intervention here intended for individuals who recurrently self-harm and have a history of contact with emergency psychiatric services. Individuals with access to Brief Admission are empowered to self-admit to inpatient care for up to three days per stay and are encouraged to do so before experiencing crisis. Brief Admission was implemented relatively recently in child and adolescent psychiatric settings in Sweden. The purpose of this study was to phenomenologically explore the lived experience of parents whose teenagers, who recurrently self-harm and experience suicidal thoughts, use Brief Admissions.MethodsThis is a qualitative study using phenomenological psychological analysis. We interviewed 17 parents who had experienced their teenagers using Brief Admissions. The interviews were recorded and transcribed verbatim and analyzed to arrive at the essential meaning structure of the phenomenon of Brief Admissions for the parent.ResultsWe identified two essential meaning structures of the parent’s experience of their teenager’s use of Brief Admissions: being gifted relief and hope or being robbed of everything you believed in. The experience of Brief Admissions as a gift was structured by the following constituents: ‘a sense of safety and containment’, ‘liberation from a hostage situation’, ‘a return to wellbeing’, and ‘catalysts for relational shifts’. In contrast, the constituents of the experience of being robbed included ‘a tug of war for control’, ‘an unworthy wasteland’, ‘abandonment and collapse of authority’, and ‘no sense of purpose and plan’.ConclusionsBrief Admissions may come across as challenging, futile and painful in the life of the parent, yet they may also support a process of recovery and healthy development for the entire family. To realize the full potential of the intervention, mental health professionals providing Brief Admission must be mindful of the challenges the parent may face as their teenager starts self-admitting, tactfully and sensitively preparing the parent for a new parental role.

Protest behaviors among patients placed in seclusion in a psychiatric emergency service.

Patients placed in seclusion for behavioral dyscontrol often perceive that the health care team is treating them inappropriately. These patients may express their indignation in many ways. To better characterize these behaviors, we conducted a study of protest behaviors in a psychiatric emergency service. Video surveillance of seclusion room occupants is routinely reviewed as part of our safety protocol. For 1 month in 2022, we noted the frequency and timing of potential protest behaviors such as disrobing and evacuation. Descriptive statistics were applied. A total of 41 seclusion events (8.1%) occurred over the surveillance period, which included 504 initial emergency psychiatric evaluations. Six patients (14.6%) engaged in protest behaviors (all within 5 minutes of being placed in seclusion), including 3 (7.3%) who urinated and 3 (7.3%) who disrobed. One patient urinated almost immediately (2.4%), and another urinated 25 minutes after entering seclusion; the latter was not interpreted as a protest behavior. Immediate behaviors in seclusion that are different from behaviors that led to seclusion can be interpreted as protest behaviors. The 2 most often observed protest behaviors were urination and disrobing.

Virtual Addiction to Video Games: Debut of Obsessive-Compulsive Disorder- Case Report and Short Review of the Literature

Abstract Introduction: Addiction is a complex condition that can be caused by substance abuse or psychological disorders related to behaviors such as gambling, food, sex, or internet gaming. A person with addiction may experience problems in inhibiting impulsivity and delaying gratification.The term “internet addiction” was first used in 1995, and it can cause a loss of control, social isolation, problems in relationships and career. Internet Gaming Disorder is characterized by a repetitive and prolonged engagement in gaming that leads to a variety of cognitive and behavioral symptoms, including social withdrawal, sleep disturbances, and obsessive-compulsive thoughts and behaviors. The physiological basis of addiction is related to the reward system in the brain, which releases dopamine in response to positive experiences. Individuals with addiction usually have problems with impulsivity and gratification, which are associated with changes in the frontal cortex. The epidemiology of internet addiction is still unclear, but it is associated with a range of personality traits. Materials and methods: we studied PubMed database to find articles related to the subject of video game addiction in relation to obsessive-compulsive disorder, for the period 2013 - 2023. We have found a number of 17 studies, the search key being “video-games addiction - obsessive - compulsive disorders”. Also, we chose to present a case of 23-year-old male presented with psychomotor agitation, anxiety, lack of sleep, and gaming addiction (17hours/ day) in the emergency psychiatric service. The patient had no psychiatric history or chronic illnesses. Results: The case highlights the impact of internet gaming addiction, particularly during the pandemic. The patient experienced symptoms of obsessive thoughts, social retraction, and psychotic symptoms, which are commonly associated with gaming addiction. Treatment with antipsychotic medication was effective in reducing symptoms. Further research is needed to understand the neurobiological mechanisms and risk factors associated with internet gaming addiction. Conclussion: Addiction can stem from both substance abuse and psychological disorders, making it a complex issue. Internet gaming disorder is a specific form of addiction that involves prolonged and excessive gaming behavior. Despite ongoing debates about diagnostic criteria and a lack of population-based studies, it is clear that internet usage has dramatically increased. The case report presented in this context demonstrates the connection between addiction and mental illness, underscoring the importance of a comprehensive approach to addiction treatment that includes addressing underlying mental health concerns.

The Medication Use Issues and Challenges of Mental Illness Exacerbation in Patients with Schizophrenia: A Qualitative Study in Thailand.

Patients with schizophrenia often experience mental illness exacerbations, which lead to frequent re-hospitalization. Non-adherence to medication is the main cause of relapses, despite many patients requiring lifelong treatment. Non-adherence consequences include higher re-admission and suicide rates, worse progression of mental illness, higher rates of violence by patients with mental illness, and increased use of emergency psychiatric services. This directly impacts the cost and workload of the mental healthcare system. This study aims to understand medication non-adherence among schizophrenia patients in Thailand based on the country's specific context. This qualitative research study explored the causes of non-adherence to medication and health perceptions among patients with schizophrenia in Thailand. Five patients with schizophrenia were included in this study. Data was collected through in-depth interviews, recordings of treatments, and field notes based on the interpretive perspective of key informants with the concept of phenomenology. Thematic analysis revealed two main themes associated with mental illness exacerbation: triggers of exacerbation and medication non-adherence. The triggers that emerged from the data were substance abuse and psychological stress. Medication non-adherence issues were misunderstandings about mental illness and its treatment, lack of participation in treatment, and difficulty accessing mental health services. This study explored the importance of medication adherence in patients with schizophrenia. Non-adherence to medication can worsen mental illness and create a vicious cycle that makes treatment more challenging. Substance abuse and psychological stress can also exacerbate this cycle. Mental health services should strive to improve medication adherence strategies and offer social support to prevent harmful behaviors and break the vicious cycle.

Impact of psychiatric social workers on length of stay in psychiatric emergency service.

Impact of psychiatric social workers on length of stay in psychiatric emergency service.

Persistence and clinical consequences of post-traumatic and dissociative symptoms in people with depressive symptoms: a one-year follow-up study

ABSTRACT Background: Recent studies found that post-traumatic and dissociative symptoms are common in people with depressive symptoms. Although a trauma-related subtype of depression has been proposed, little is known about the persistence and clinical consequences of these symptoms. Objective: This one-year follow-up study investigated the persistence and clinical consequences of post-traumatic and dissociative symptoms in people with depressive symptoms. Methods: We analyzed longitudinal data from an international sample of people self-reporting depressive emotions (N = 152) (mean Patient Health Questionnaire-9 score = 17.27; SD = 6.31). Results: More than half (58.4%) of participants with baseline post-traumatic stress disorder (PTSD) still met the criteria for PTSD after one year. Participants with dissociative symptoms at baseline were significantly more likely to report lifetime psychiatric hospitalization (31.2% vs 14.7%), past-year use of psychiatric hospitalization (10.4% vs 0%) and emergency services (16.9% vs 4%) than those without dissociative symptoms. All post-traumatic and dissociative symptom clusters were cross-sectionally (r = .286 to .528, p < .001) and longitudinally (r = .181 to .462, p < .001) correlated with depressive symptoms. A sense of current threat (β = .146, p < .05) and negative self-concept (β = .173, p < .05) at baseline significantly predicted depressive symptoms after one year. Conclusions: These findings contribute to the increasing body of knowledge regarding the PTSD/dissociation-depression comorbidity. Given their persistence and clinical consequences, we recommend that post-traumatic and dissociative symptoms be regularly screened for in clinical settings. The existence of a possible trauma-related subtype of depression should receive more attention in both research and clinical practice.

Telephone Assessment of Suicidal Risk at Prehospital Emergency Medical Services: A Direct Comparison with Face-to-Face Evaluation at Psychiatric Emergency Service

Objective Assessment of suicidal risk is one of the most challenging tasks faced by health professionals, notably in emergency care. We compared telephone suicide risk assessment at prehospital Emergency Medical Services Dispatch Center (EMS-DC), with subsequent face-to-face evaluation at Psychiatric Emergency Service (PES), using French national Risk-Urgency-Danger standards (RUD). Method Data were collected for all suicidal adult patients (N = 80) who were addressed by EMS-DC to PES between December 2018 and August 2019 and benefited from RUD assessment at both services. Suicidal risk was given a score of 1, 2, 3 or 4, in order of severity. Results Mean of the differences between the RUD score at EMS-DC and PES was −0.825 (SD = 1.19), and was found to be significant (p < 0.01). The average time between RUD assessments was 420 min (SD = 448) and was negatively correlated with the difference in the RUD score (r = −0.295, p = 0.008). Associated suicide attempt increased the odds of a decrease in the RUD score (OR = 2.989; 95% CI = 1.141–8.069; p < 0.05). Conclusions Telephone evaluation of suicidal risk using RUD at EMS-DC yielded moderately higher scores than those obtained by a subsequent face-to face evaluation at PES, with this difference partially explained by the time between assessments, and by clinical and contextual factors.

6.79 Comparing Suicidal Ideation in Children and Adolescents Presenting to a Comprehensive Psychiatric Emergency Program Across 2 Years of the Pandemic

6.79 Comparing Suicidal Ideation in Children and Adolescents Presenting to a Comprehensive Psychiatric Emergency Program Across 2 Years of the Pandemic

6.24 Characteristics of Children, Adolescents, and Young Adults With Neurodevelopmental Disorders Who Are Presenting to Psychiatric Emergency Services

6.24 Characteristics of Children, Adolescents, and Young Adults With Neurodevelopmental Disorders Who Are Presenting to Psychiatric Emergency Services

Psychiatric Boarding Patterns Among Publicly Insured Youths Evaluated by Mobile Crisis Teams Before and During the COVID-19 Pandemic

Psychiatric boarding occurs when patients needing intensive psychiatric services who are already under clinical supervision experience delays in their admission to psychiatric facilities. Initial reports have suggested that the US had a psychiatric boarding crisis during the COVID-19 pandemic; however, little is known about the consequences of this crisis for publicly insured youths. To estimate pandemic-associated changes in psychiatric boarding rates and discharge modalities for people aged 4 to 20 years who accessed psychiatric emergency services (PES) through a mobile crisis team (MCT) evaluation and were covered by Medicaid or health safety net programs. This retrospective cross-sectional study used data from the MCT encounters of a multichannel PES program in Massachusetts. A total of 7625 MCT-initiated PES encounters with publicly insured youths who lived in Massachusetts between January 1, 2018, and August 31, 2021, were assessed. Encounter-level outcomes (psychiatric boarding status, repeat visits, and discharge disposition) during a prepandemic period (January 1, 2018, to March 9, 2020) were compared with outcomes during a pandemic period (March 10, 2020, to August 31, 2021). Descriptive statistics and multivariate regression analysis were used. Among 7625 MCT-initiated PES encounters, the mean (SD) age of publicly insured youths was 13.6 (3.7) years; most youths identified as male (3656 [47.9%]), were of Black race (2725 [35.7%]) or Hispanic ethnicity (2708 [35.5%]), and spoke English (6941 [91.0%]). During the pandemic period, the mean monthly boarding encounter rate was 25.3 percentage points higher than the prepandemic period. After adjustment for covariates, the odds of an encounter resulting in boarding doubled during the pandemic (adjusted odds ratio [AOR], 2.03; 95% CI, 1.82-2.26; P < .001), and boarding youths were 64% less likely to be discharged to inpatient psychiatric care (AOR, 0.36; 95% CI, 0.31-0.43; P < .001). Publicly insured youths who boarded during the pandemic had significantly higher rates of 30-day readmissions (incidence rate ratio, 2.17; 95% CI, 1.88-2.50; P < .001). Boarding encounters during the pandemic were significantly less likely to end in discharge to inpatient psychiatric units (AOR, 0.36; 95% CI, 0.31-0.43; P < .001) or community-based acute treatment facilities (AOR, 0.70; 95% CI, 0.55-0.90; P = .005). In this cross-sectional study, publicly insured youths were more likely to experience psychiatric boarding during the COVID-19 pandemic and, if boarding, were less likely to transfer to a 24-hour level of care. These findings suggest that psychiatric service programs for youths were not prepared to support the levels of acuity and demand that emerged from the pandemic.

Integrating Psychiatric Services in the Emergency Room to Improve Patient Care by Using Quality Improvement Methods.

Prolonged length of stay in emergency departments (EDs) for patients with a psychiatric chief complaint is a widespread problem. Prolonged stays can lead to adverse outcomes and poor quality of care. We sought to improve quality of care for patients in the medical ED who needed psychiatric care. To identify the areas of weakness, we queried the ED staff via an online survey about the perception of the challenges working with our Comprehensive Psychiatric Emergency Program (CPEP), which is located adjacent to and works closely with the medical ED providing psychiatric consultation. We identified several action steps and used the Plan-Do-Study-Act methodology for implementation. We reported a reduction in time to complete consultations and improved communication between CPEP and the medical ED staff.

Mental Health of Children and Adolescents before and during the COVID-19 Pandemic: How Did the Lockdown Modify Psychiatric Emergencies in Tuscany, Italy?

The COVID-19 pandemic has deeply impacted several aspects of the lives of children and adolescents. We analyzed the trends of psychiatric disorders in the emergency room. The analysis comprised the pre-pandemic (2018-2019) and the pandemic years (2020-2021). We conducted a retrospective observational epidemiological study that compared admissions during the two periods on a sample of 1311 patients aged between 4 and 18, focusing on new admissions vs. relapse, demographic variables, lockdown severity, presentation of psychiatric symptoms, diagnosis, severity, and outcome. Over the two-year pandemic period, we observed a 33% decrease in admissions to the emergency room for non-psychiatric disorders and a 200% increase in admissions for psychiatric emergencies. This increase is concentrated in periods with fewer restrictions and in the second year of the pandemic. We also observed a greater impact of psychiatric disorders on female patients, a greater severity of psychiatric disorders, a change in diagnoses associated with the presentation of symptoms, and an increase in hospitalizations. The children's psychiatric emergency service faced an "emergency within the emergency". In the future, it will be necessary to continue the follow-up of these patients, strengthen the field of study of gender psychiatry, and intensify our efforts towards prevention.

Network analysis of comorbid depression, suicidality and biomarkers on HPA axis among mood disorder patients to psychiatric emergency services

Rapid assessment and intervention of suicide risk are common and challenging in psychiatric emergency departments (PED). It is unclear whether distinct pathophysiological processes exist among depressive patients with suicidality. This study examined the network structures of biomarkers on Hypothalamic-Pituitary-Adrenal (HPA) axis, such as Adrenocorticotropic hormone (ACTH) and Corticosterone (Cort), as well as suicidality and depressive symptoms in mood disorder patients in PED. Mood disorder patients in PED were assessed with the measurements of suicidality and depressive symptoms, respectively. A network analysis was performed to identify central symptoms and bridge symptoms of this network and their links to ACTH and Cort. Network stability was examined using the case-dropping procedure. The Network Comparison Test (NCT) was conducted to evaluate whether network characteristics differed by gender. A total of 1815 mood disorder patients were recruited. The prevalence of SI was 31.2% (95% CI: 28.15–34.21%), SP was 30.4% (95% CI: 27.39–33.41%), SA was 30.62% (95% CI: 27.61–33.64%) among psychiatric outpatients. The mean score of HAMD-24 was 13.87 ± 8.02. Network analysis revealed that ‘Somatic anxiety’ had the highest expected centrality, followed by ‘Hopelessness’ and ‘Suicide attempt’. ‘Corticosterone’ and ‘Retardation’ may be the main bridge symptoms between depressive symptoms and the suicidality community. The network model showed a high degree of stability. Gender did not significantly influence the network structure. The central symptoms and key bridge symptoms identified could be potential targets for interventions of the HPA axis, which is designed for regular screening of a range of suicidal activity. In the light of this, timely treatment should be provided for psychiatric emergency care.

Trajectories of children and adolescents attending a psychiatric emergency unit during the COVID-19 confinements: 2020–2022 longitudinal study

IntroductionThe prevalence of psychiatric disorders has not shifted widely through the COVID pandemic, except for some specific groups such as young people or women. Our objective is to examine prospectively the evolution of children and adolescents who consulted in a psychiatric emergency service during the COVID-19 confinements.MethodWe collected prospective clinical information about 296 young people under 18 who visited a tertiary hospital for psychiatric reasons during the confinement periods in Spain. Clinical diagnoses, suicide attempts, hospital admissions, and pharmacological prescriptions were extracted from electronic health records through 2020, 2021, and 2022. Features of those who maintained psychiatric care and those who did not were compared.ResultsThree out of four children and adolescents who visited the psychiatric emergency department during the confinements continued psychiatric care at the end of 2022. Those who did not showed better premorbid adjustment at baseline. During follow-up, diagnoses of neurodevelopmental disorders and eating disorders, as well as the dosage of psychotropic drug prescriptions, increased. The diagnoses of major depressive disorder and eating disorder at baseline were associated with attempting suicide during follow-up. Patients with internalizing symptoms were admitted earlier than those with externalizing symptoms but no differences were found in terms of suicide attempts.ConclusionsThe continuity of psychiatric care after an initial emergency visit during the confinements implied greater clinical severity, as reflected by changes in clinical diagnoses and pharmacological regimens. Emergent symptoms of depression or eating disorders after social distancing or isolation could predict subsequent suicidal behavior in young populations.

An Integrated Behavioral-Neuropsychiatric Treatment Plan Reduces Severe Challenging Behavior in an Adolescent With Neurobehavioral Complications of Neonatal Brain Injury

We present the case of a 15-year-old adolescent boy with a neurobehavioral disorder who experienced a brain injury during the first month of life. The forms of challenging behaviors were severe and included aggression, property destruction, volitional incontinence, and suicidal statements, and had resulted in two psychiatric hospitalizations and multiple emergency evaluations prior to intervention. The intervention was preceded by a functional behavior assessment suggesting that a differential reinforcement intervention could be designed to minimize reinforcement of challenging behaviors while maximizing reinforcement of adaptive, positive behaviors. The intervention was introduced following the baseline phase and there was an immediate decrease in the rate of challenging behaviors and in the utilization of emergency psychiatric services. Improvements continued for 6 weeks, after which a medication was added to promote sleep onset (to decrease sleep onset latency) along with behavioral guidelines, which led to further improvements for an additional 12 weeks. A follow-up phase of 3 months showed sustained results. The study illustrates the value of an integrated approach utilizing applied behavior analysis and sequenced neuropsychiatry, and a neurobehavioral formulation where components of the participant’s brain injury history are integrated with an operant formulation as circumstances that explain the problem behavior while effectively suggesting strategies for behavioral treatment. Because the intervention was implemented by support staff in a group home, it illustrates the ability of support staff to work therapeutically with severe behavior presentations using structured behavioral interventions.

Physical injuries as triggers for self-harm: a within-individual study of nearly 250 000 injured people with a major psychiatric disorder

BackgroundAlthough there is robust evidence for several factors which may precipitate self-harm, the contributions of different physical injuries are largely unknown.ObjectiveTo examine whether specific physical injuries are associated with risks...

Longitudinal Outcomes of the top 20 Utilizers of VA Connecticut's Psychiatric Emergency Services Between 2010 and 2020.

Frequent utilizers of emergency services represent a clinically important cohort with potentially unmet health care needs despite demanding a high volume of costly services. However, not much is known about their longitudinal course. This study identified the top 20 utilizers of VA Connecticut's psychiatric emergency services and conducted a chart review of their longitudinal outcomes during an 11-year period between 2010 and 2020, including their visit diagnoses, medical and psychiatric comorbidities, and types and frequency of other medical services and supports received. At the index visit, 19 of the 20 patients had substance use disorder and 14 patients had at least one non-substance psychiatric diagnosis. Despite all patients receiving primary care and other services, such as residential treatments, outpatient therapy, and social work consults, 11 of the 12 patients remaining alive and residing in the state continued to utilize psychiatric emergency services in 2020, revealing a pattern of persistent use.