Children and adolescents in the psychiatric emergency setting.

Emergencies in child and adolescent psychiatry are not uncommon, occur in a variety of settings, and require referral to resources offering different levels of care. Clinicians must be familiar with basic tenets of emergency assessment and treatment whether practicing alone in a rural area or as part of an interdisciplinary team in a busy urban hospital. Recommendations for future research include gathering more extensive epidemiologic data and data regarding practice patterns nationwide and conducting more psychopharmacologic research into the management of patients with acute agitation, aggression, and violence. In addition, outcome data to support provision of necessary inpatient and outpatient services must be collected. The development of successful strategies to prevent psychiatric emergencies in children and adolescents is equally important.     

Asperger's disorder in the emergency psychiatric setting

Asperger's syndrome (AS) is a pervasive developmental disorder that may be unrecognized, especially if signs of other psychiatric disorders coexist. The objectives of this paper are: 1) to ascertain the prevalence of AS in the emergency psychiatric setting; and 2) to describe features of AS which may help to differentiate these patients from patients with psychotic disorders. Among 2500 patients admitted to a psychiatric intensive care unit, 5 (0.2%) received a diagnosis of AS, for the first time. Besides impairment of social interaction, common features were the following: male gender, left handedness, obsessive-compulsive symptoms, cognitive hyper-abilities, violent behavior, sense of humor, low WAIS total score, high WAIS verbal/performance score ratio, unusual, restricted interest and clumsiness. Comorbid schizophrenia is difficult to rule out in these patients. Psychotic symptoms should not be overvalued in making the diagnosis when specific features of AS are present.     

Medical assessment in the psychiatric emergency service.

This chapter examines the frequency and consequences of medical morbidity in psychiatric presentations and reviews the factors that should influence policy decisions surrounding "medical clearance" in PES settings.     

The psychiatric clinical specialist''s impact on psychiatric emergency services

Psychiatric emergency services have evolved into more comprehensive programs during the past two decades. With this evolution other disciplines have gained access to the services and integrated their expertise and philosophy into the daily care of patients. Nursing has been an integral part of this process and contributed its perspective in nursing care. This paper outlines the development of psychiatric emergency services with a special emphasis on the contribution of nursing specialists who have developed their role within the psychiatric emergency service.

What has been unique about the nursing contribution is the attention to individualizing patient care and modifying treatment approaches to meet the patients' needs and interests in psychiatric treatment. Additionally, nursing has complemented the physician's role by developing expertise in assessment that is both psychologically and biologically oriented. Nursing's future contribution to psychiatric emergency services should address mechanisms for tracking patients who enter the psychiatric emergency service system with an emphasis on linkage with other programs or resolution of the crisis episode.     

Definitive treatment in the psychiatric emergency service

This article briefly reviews the history of psychiatric emergency services (PES) in the United States and concludes that the dominant model, the triage model, unnecessarily limits modern PES. Trends in the mental health system and the corresponding development of compensatory PES structures are described. These include observation units, outreach, and crisis residential treatment and other innovations. These new structures have had the effect of increasing the length of stay in emergency services, increasing the number and complexity of services provided in the PES and professionalizing emergency service personnel. A new model, the treatment model, is proposed for this type of PES. Strategies for the rapid initiation of definitive treatment of bipolar disorder, schizophrenia, major depression and opiate addiction are outlined for services with this capability.     

Utility of routine drug screening in a psychiatric emergency setting

OBJECTIVE: The study determined whether dispositions from an urban psychiatric emergency service would differ between patients who received a mandatory urine drug test and those who may or may not have had a test based on the attending psychiatrist's clinical judgment. The accuracy of clinicians' suspicion of substance use among mandatorily screened patients was also examined. METHODS: A total of 392 consenting patients presenting to an urban psychiatric emergency service were randomly assigned to a mandatory-screen group (N=198) or a usual-care group (N=194). Physicians ordered screens based on clinical judgment. Additional screens were performed without physicians' knowledge for patients in the mandatory-screen group for whom no screen was ordered. Demographic and clinical information, results of drug screens, and information about dispositions were collected from clinical charts or hospital databases. RESULTS: No difference in dispositions was found between the mandatory-screen group and the usual-care group. Survival analysis did not reveal a difference between the two groups in length of stay in inpatient psychiatric units. As for accuracy of physicians' suspicion of substance use, positive drug screens were recorded for 10.2 percent of the 198 patients in the mandatory-screen group who did not admit drug use or for whom physicians did not expect drug use. A total of 39.3 percent of the patients who were suspected of use and 88.2 percent of those who admitted use had positive drug screens. Only 20.8 percent of patients who denied substance use had positive screens. CONCLUSIONS: Routine urine drug screening in a psychiatric emergency service did not affect disposition or the subsequent length of inpatient stays. The results do not support routine use of drug screens in this setting.     

Violence and suicide risk assessment in the psychiatric emergency room

Structured clinical rating scales covering 10 areas related to suicide and violence were constructed for use in a psychiatric emergency room (ER). Ninety-five ER patients were evaluated with the scales, 50 of whom were discharged after the visit and 45 of whom were admitted to the inpatient psychiatric wards of the hospital. The admitted patients were found to differ significantly from the discharged patients on every one of the 10 scales. Scores on the scales were also found to predict suicide precautions on the wards, harrassment of other patients as assessed from nursing notes, and indicators of violence on the wards. The scales were also found to have high internal reliability and high sensitivity and specificity. They appear to be helpful to clinicians in identifying patients in need of hospitalization and may also serve as limited predictors of hospital functioning.     

Phenomenology and treatment of psychotic disorders in the psychiatric emergency service.

The emergency evaluation of a psychotic patient calls on all of the skills of the psychiatrist. The immediate control of dangerous behavior takes place at the same time that clinicians evaluate patients for delirium. A screening physical examination, a brief mental status examination, and a high index of suspicion for medical diseases are essential tools in the first few minutes of a patient's stay in the psychiatric emergency service. Drugs of abuse are often part of a patient's presentation. Here, too, the first task is to rule out delirium, particularly from sedative or alcohol withdrawal. As soon as a patient's condition is stabilized, the psychiatrist should review all of the available information, develop a working diagnosis, and initiate definitive treatment of the presumed disorder. With fewer emergency patients being hospitalized and with shorter lengths of hospital stay, these initial decisions acquire increasing significance for patient outcome.     

The impact of capitated financing on psychiatric emergency services

OBJECTIVE: Studies of capitated financing of mental health services have generally focused on the cost and utilization of services. Relatively little research has addressed whether capitation has an impact on the effectiveness of the mental health system as a whole. This study examined the impact of capitation on hospital emergency department visits, a widely cited indicator of the effectiveness of the other components of the system. METHODS: In 1995 Colorado's Medicaid program instituted capitation for mental health services in two areas of the state, one in which reimbursement of not-for-profit providers was directly capitated and another in which not-for-profit providers partnered with a for-profit managed behavioral health organization. The analysis examined variation over time in the number of emergency department visits by adults who had a primary mental or substance use disorder. Using interrupted time-series methods, visits in areas where reimbursement was capitated were compared with visits in areas where providers continued to be reimbursed on a fee-for-service basis. A total of 105 weeks for each area was examined; capitation was implemented at week 53. RESULTS: The number of psychiatric emergencies treated in capitated areas declined by 814 (28 percent) below the 2,908 psychiatric emergencies expected from trends, cycles, and levels in fee-for-service areas. Findings were similar for for-profit and not-for-profit areas. The decrease persisted through the end of the first year after capitation. CONCLUSIONS: In Colorado the implementation of capitation was associated with a sustained decrease in utilization of psychiatric emergency services provided by hospital emergency departments. Our findings suggest that capitation does not necessarily reduce the quality of care provided to clients.     

Civil commitment in the psychiatric emergency room. I. The assessment of dangerousness by emergency room clinicians

Critics of the dangerousness standard for civil commitment contend that there is no professional standard for the evaluation of dangerousness. We used Three Ratings of Involuntary Admissibility, a reliable index of behavioral indicators of danger to self, danger to others, and grave disability, and found that when combined into weighted patterns these indicators predicted disposition decisions of 70 clinicians in five psychiatric emergency rooms over 251 cases. A concurrent measure of perceived dangerousness, Clinician's Global Ratings of patients on these criteria, yielded similar results. We conclude that clinicians in California psychiatric emergency rooms apply a shared concept of dangerousness that can be described in behavioral terms.     

The evolution of a psychiatric emergency crisis intervention service in a medical emergency room setting

The evolution of a modern day multidisciplinary psychiatric service in the emergency room of the CGH has been described. The importance of administrative and organizational factors has been underlined. There has been a focus on the delivery component of such a service with reference to the training and support necessary to the morale and growth of team members and ultimately to the delivery of quality care in a most stressful area. A return to careful clinical thinking about emergency room patients has been suggested. Brief mention was made of beginning attempts at research and evaluation of the operation. There have been comments on movement towards a county-wide psychiatric service and, finally, some suggestions as to what would constitute an ideal service.     

Violent patients in the emergency setting.

Violent or threatening behavior is a common reason for presentation to the ED. Patients with aggressive behavior must first be assessed for the possibility of comorbid medical conditions. Acute withdrawal from alcohol or sedatives needs to be ruled out. Short-term sedation with lorazepam is a safe and effective choice for managing patients with acute agitation. The use of typical neuroleptics may lead to side effects, such as akathisia, which may in turn precipitate additional agitation. This may be obviated with the introduction of IM preparations of atypical antipsychotics.     

The treatment capabilities of psychiatric emergency services

The author describes the treatment capabilities of a psychiatric emergency service. Psychiatric emergency facilities have become an integral part of general hospitals and the mental health system, and are used increasingly by patients. The author defines the treatment goals of psychiatric emergency care as, (1) symptomatic relief, (2) maintenance of ongoing treatment, and (3) referral and facilitation for entering treatment. The treatment techniques include an integration of psychologic, pharmacologic, and physical management principles. The qualities needed by an emergency service clinician to work in such a setting are described. Implications for training and research are discussed.     

Treatment strategy for women with puerperal psychiatric disorders--psychopharmaco-therapy and its impact on fetus and breast-fed infants]

Women have the most possibility of suffering from mental disorders during pregnancy and postpartum periods in their whole life time. Especially, postnatal depression is not uncommon with an incidence of 10-20%, fortunately a screening system has been developed, and in Japan the Edinburgh Postnatal Depression Scale (EPDS) is now practically used in both hospitals and community health service centers. Additionally most mental disorders during this period are not severely disturbed, so they do not have to be necessarily treated by psychiatrists. Severely disturbed cases, however, which include postnatal depression with self or infant harm thought or puerperal psychosis are to be treated by psychiatrists and tend to have psychopharmaco-therapy. In using psychotropic drugs attention must be paid for both women and their babies. Impact on breast-fed babies while mothers take psychotropic drugs have been reported, mostly as case reports. We have reported the controlled studies, (1) The 25 mothers with postnatal depression were treated by tricyclic antidepressants, of which 10 breast-fed and 15 did not. The drugs were amitriptyline, imipramine, clomipramine, dothiepine, (2) The 30 mothers with puerperal psychosis were treated by antipsychotic drugs, of which 12 breast-fed and 18 did not. The drugs were chlorpromazine, trifluoperazine, perphenazine and haloperidol. Both antidepressants and neuroleptics were transferred through breast-milk and a few % of maternal dose per kilogram were injected to their babies by calculating drug concentration ratios of in breast-milk/in serum. None of the breast-fed infants had adverse effects, and no developmental difference was found compared to bottle-fed infants using the Bayley Development Scale during infancy. Furthermore, the breast-fed infants were followed up as long as possible up to 30 months and no significant developmental delay was found. In addition, we reported a case study on four breast-fed babies whose mothers took fluoxetine. The infants had no adverse effects. Pregnant women and their fetuses need to be more carefully monitored. Three preliminary cases were reported here; the pregnant women took clomipramine, sulpiride, haloperidol and chlorpromazine. Drug concentrations in maternal plasma in late pregnancy and postnatally and in umbilical cords were almost the same, which meant they were freely transferred from mothers to babies. Regarding the neonate's outcome, all were full turn born with normal birth weight with good Apgar scores. Weight gain in one month was normal which meant all babies had normal sucking without hypotonic muscle. Psychiatrists must accumulate these date and contribute as one of specialists in perinatal mental health in multi-disciplinary team.