What do psychiatric emergency patients really want and how do they feel about what they get?

Psychiatric emergency patients range along a continuum from persons who present to the service with specific requests for help, to individuals who are brought to the service in handcuffs against their will for reasons they do not understand. In addition, studies suggest that psychiatric emergency patients' wishes and expectations often fall outside the traditional framework of psychiatric assessment (1), are not straightforward or concrete (2) or are not accurately perceived by the clinicians who see them (3). How these factors impact on patient satisfaction with the treatment they have received is not well-understood, because the manner in which specific patient variables and treatments might relate to patient satisfaction among the psychiatric emergency service population has not been systematically studied (4) (5) (6). In contrast, psychiatric inpatients and outpatients (7) (8) (9) usually express positive attitudes about their mental health care, although this finding may be skewed by a lack of real anonymity (10). Chronic patients tend to express less satisfaction with their treatment programs than do others, and patient satisfaction in some studies has been related to patient demographics, diagnoses, treatment histories (11) and patients' global rating of treatment outcome (12).     

Psychiatric disorders among patients admitted to a French medical emergency service

OBJECTIVE: The authors assessed the prevalence of psychiatric disorders among a population of patients examined in the emergency service of a French general hospital. They compared patients with and without psychiatric disorders. They also compared patients where the primary motive of emergency was psychiatric to those whose psychiatric disorders were secondarily diagnosed by a systematic assessment. METHOD: Five hundred consecutive patients admitted to the emergency service of Bichat Claude Bernard Hospital (Paris, France) were interviewed with standardized questionnaires. Demographic details were collected along with information on current and past contacts with emergencies and psychiatric services. Psychiatric disorders were identified using a structured psychiatric interview, the Mini International Neuropsychiatric Interview (MINI). Domestic violence was identified with a specific checklist validated for this purpose. RESULTS: Prevalence of psychiatric disorders was 38% (189 patients). Forty (8%) patients were primary psychiatric cases referred to the emergency department for psychiatric reasons, while 149 (30%) were secondary psychiatric cases, as revealed by a systematic assessment of their mental state. Psychiatric patients, primary or secondary, were more often homeless (13.6% vs.1.95%). They had been more often referred to the emergency department after an aggressive (7.4% vs.3.5%) or violent behavior (5.8% vs.0.9%) and less often after an accident (8.4% vs.14.3%). Psychiatric patients were more often examined after an episode of domestic violence (21.7% vs. 6.8%). Psychiatric diagnoses, according to the DSM-IV criteria, were depression (80 cases), generalized anxiety disorder (34 cases) acute alcohol intoxication (21 cases), alcohol dependence (20 cases), schizophrenia (16 cases), posttraumatic stress disorder (14 cases), drug abuse (4 cases), agoraphobia (4 cases), alcohol abuse (3 cases), anorexia nervosa (3 cases), mania (2 cases) and obsessive compulsive disorder (2 cases). The proportion of psychiatric diagnoses was equivalent in primary and secondary psychiatric cases except for schizophrenia (more often a primary demand for psychiatric help) and acute alcohol intoxication (more often revealed by a systematic assessment of the mental state). CONCLUSION: Thirty-eight percent of the patients examined in a French emergency service presented with psychiatric disorders. The majority of the patients (78%) were not referred to the emergency service for psychiatric reasons. Patients seen in an emergency service should thus be identified as a population at risk for psychiatric disorders whatever their reason for utilizing this service.     

Families' experiences in psychiatric emergencies

Sixty families from three self-help, psychoeducational groups in western New York State were interviewed about their experiences during recent psychiatric emergencies involving their mentally ill relatives. Twenty-six hospital-based emergency mental health service providers were compared with the families on key attitudes toward emergency services. Families reported that emergencies were complicated and traumatic and that they involved contacts with numerous agencies, sometimes over several months. Satisfaction with the emergency service system was generally low among both families and hospital service providers. Service providers were less likely than families to believe that families' assessments of their ill relatives' need for treatment were credible. The author suggests that apparently "crazy" behavior of families may make sense in the context of serious patient pathology and a general lack of emergency assistance. Much effort is needed to develop coordinated emergency mental health treatment that is sensitive to families' needs.     

Psychiatric consultation to a general hospital medical evaluation service

Psychiatric consultation to a general hospital medical evaluation service was reviewed and compared with consultation patterns for general hospital inpatients and psychiatric emergency service patients. Results of a questionnaire survey indicated nearly 1 in 5 patients admitted to this acute medical service (24-hour maximum stay) required psychiatric consultation. A study of those patients seen by psychiatric consultants is reported. The prevalence of depressive illness as well as the psychiatric hospitalization referral rate was substantially greater than in general hospital inpatient or psychiatric emergency service evaluations. The implications of this relatively new area of consultation-liaison for hospital staffing and medical education are discussed.     

The nature of help-seeking during psychiatric emergency service visits by a patient and an accompanying adult

Utilization rates for urban psychiatric emergency services remain high, and the decision to seek care in this setting is poorly understood. Three hundred individuals accompanying patients to a psychiatric emergency service were interviewed about their help seeking and choice of treatment setting. Twenty-three of the interviewees (7.7 percent) were caregivers accompanying patients with severe and persistent mental illness. They were significantly more likely than other interviewees to know the difference between psychiatric emergency services and services offered by other outpatient providers. More than half reported that the patient they accompanied was intermittently noncompliant, which required visiting either a walk-in service during a moment when the patient was cooperative or a facility equipped to provide involuntary treatment.     

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.     

Alcohol dependence among patients admitted to psychiatric emergency services

We assessed the prevalence of alcohol dependence among patients examined in the psychiatric emergency service of a general hospital. We compared socio-demographic data and psychiatric status of patients with and without alcohol dependence. One-hundred and four consecutive patients received by the psychiatric emergency service of Bichat-Claude Bernard Hospital (Paris, France) were assessed. Diagnosis of alcohol dependence, acute alcohol intoxication, and antisocial personality was determined according to DSM-IV criteria. Other psychiatric disorders were identified using a structured psychiatric interview, the Mini International Neuropsychiatric Interview (MINI). Prevalency rate of alcohol dependence was 37.5% among patients examined by the psychiatric emergency service. Alcohol-dependent patients were more often men than women and more often unemployed than non-alcohol-dependent psychiatric emergencies. They presented more dysthymia, acute alcohol intoxication, and antisocial personality than non-alcoholic patients followed by the psychiatric emergency service. Attempted suicide was as frequent in alcohol-dependent patients (23%) as in other patients (29%). Alcohol-dependent patients consumed alcohol more often when alone, and their alcohol consumption began more frequently in the morning. Patients seen in a psychiatric emergency service must be identified as a population at risk for alcohol dependence (37.5%). Alcohol-dependent patients are more often men and have a higher rate of unemployment. They present significantly more often dysthymia and acute alcohol intoxication associated to alcohol dependence.     

Negotiating psychiatric hospitalizations within restrictive admissions criteria

A study of 189 consecutive psychiatric dispositions from the emergency service of an urban university hospital illustrates the difficulty that emergency psychiatric clinicians face when trying to find a receiving institution for a patient requiring hospitalization. All 18 of the receiving systems used by the service had restrictive admissions criteria that affected the admissions of specific patients, among them presence or absence of health insurance, voluntary or involuntary status, willingness of the family to participate in treatment, and patient's sex and age. Four case reports taken from the 189 dispositions demonstrate how clinicians must present patients to admitting staff in a manner that convinces an institution to admit them. The consequences of this practice are discussed, as are potential solutions to disposition difficulties.     

'Time slip' phenomenon in adolescents and adults with autism spectrum disorders: case series

In recent years, it has been noticed that adolescent and adult patients with autism spectrum disorder (ASD) sometimes visit psychiatric medical institutions. In some cases, these patients commit an act of violence and are dealt with by psychiatric emergency and forensic psychiatric services. In this report, we present two cases with ASD who visited a psychiatric emergency service because of the 'time slip' phenomenon, and discuss the clinical significance of this phenomenon.     

La dépression aux urgences psychiatriques : une expérience quotidienne

Depression is the most common psychiatric disorder in the general population, and emergency room visits for depression have been increasing for several years. In addition, the Covid-19 pandemic may lead to an explosion of psychiatric emergency room visits for this reason, with an overall prevalence of anxiety and depression that appears to be increasing since 2020. The Centre Psychiatrique d’Orientation et d’Accueil is a regional psychiatric emergency service located in Paris which records approximately 10,000 consultations per year. Among these consultations, the main symptoms are those of depression (depressive ideations, anxiety) and nearly 40 % are diagnosed with mood disorders, including depression. The management of the patient in the emergency room is based on a global evaluation, which should not be limited to the psychiatric interview. In the best case, and if compatible with the organization of the service, an initial evaluation by the nursing reception staff determines the context of the arrival of the patient, the reason and the degree of urgency of the consultation can thus be assessed from the outset. The request for care can come from the patient themself, but also from family and friends who are worried about a decline in the patient's previous condition. The consultation may also be triggered by the intervention of emergency services, particularly in the case of attempted suicide or agitation. The context of arrival, the environment, and the patient's entourage must be taken into account in order to achieve an optimal orientation. Particular attention must be paid to the first episodes (elimination of a differential diagnosis, screening for a possible bipolar disorder). The existence of an external causal factor or a comorbid personality disorder should not trivialize the consultation and lead to a faulty diagnosis of a characterized depressive episode. Drug treatment in the emergency room is usually symptomatic (anxiolytic treatment with benzodiazepines or neuroleptics, depending on the situation), and outpatient referral should always be preferred. Therapeutic adaptations can then be considered. The decision to hospitalize must always be justified, and consent for care must be rigorously evaluated. It is almost always necessary to take the patient's entourage into account as well as the potential support of the patient by the entourage. All these elements must be recorded in the file. Suicide risk assessment must be systematic for all patients consulting psychiatric emergencies, and the use of the RUD (Risk, Urgency, Dangerousness) grid can be useful. Any decision to release a patient with suicidal tendencies must be made strictly following certain conditions:a rapid psychiatric re-evaluation of the crisis, with for example the proposal of a post-emergency consultation, a supportive entourage, accepted symptomatic treatment. The registration of the suicidal patient in a monitoring system such as VigilanS can also be beneficial and reduce the risk of recidivism.     

An emergency psychiatry update

A review of trends in emergency psychiatry since 1981 indicates that the scope and complexity of the field have greatly increased. Clinicians have found it useful to identify patient groups with special assessment and treatment needs, including adolescents, the elderly, victims of rape and of domestic violence, and repeat visitors to the emergency service. The spread of AIDS requires greater medical attentiveness by psychiatric emergency clinicians, and two recreational substances of abuse, cocaine and inhalants, have become increasingly popular. The use of psychotropic drugs in the emergency room has received more attention, and new trends in rapid tranquilization are apparent. Also reviewed are current medicolegal controversies related to emergency room practice, findings on prediction and control of violence, and the use of the psychiatric emergency service as a training site.     

Need and demand in psychiatric emergency service utilization: explaining topographic differences of a utilization sample in Mannheim

Up to now all investigations about the topographic distribution of psychiatric utilization rates ignore whether or not the patients really require care (need for care) respectively express that need by themselves (demand for care). To analyze utilization rates of the psychiatric emergency service of the Central Institute of Mental Health in Mannheim (CIMH), variables differentiating between need and demand for emergency care were included. The investigation is based on contacts in the psychiatric emergency service between 1982 and 1993 and comprises 6463 patients with 14,628 contacts. To operationalize the concepts of need and demand the items “instance of consultation”, “reasons for consultation”“inpatient admission” and “rated urgency” from the standardized record system of the psychiatric emergency service were used. The association between need, demand and ecological, socio-demographic and distance-related factors were analyzed. The results show that demand for psychiatric emergency care is an important factor for explaining topographic diferences in service utilization. Demand correlates with ecological, socio-demographic and distance related factors; need only correlates with age. The amount of demand also varies with specific mental disorders. Received: 21 July 1999 / Accepted: 31 May 2000     

Psychiatric emergency service use and homelessness, mental disorder, and violence

OBJECTIVE: This study examined relationships between homelessness, mental disorder, violence, and the use of psychiatric emergency services. To the authors' knowledge, this study is the first to examine these issues for all episodes of care in a psychiatric emergency service that serves an entire mental health system in a major city. METHODS: Archival databases were examined to gather data on all individuals (N=2,294) who were served between January 1, 1997, and June 30, 1997, in the county hospital's psychiatric emergency service in San Francisco, California. RESULTS: Homeless individuals accounted for approximately 30 percent of the episodes of service in the psychiatric emergency service and were more likely than other emergency service patients to have multiple episodes of service and to be hospitalized after the emergency department visit. Homelessness was associated with increased rates of co-occurring substance-related disorders and severe mental disorders. Eight percent of persons who were homeless had exhibited violent behavior in the two weeks before visiting the emergency service. CONCLUSIONS: Homeless individuals with mental disorders accounted for a large proportion of persons who received psychiatric emergency services in the community mental health system in the urban setting of this study. The co-occurrence of homelessness, mental disorder, substance abuse, and violence represents a complicated issue that will likely require coordination of multiple service delivery systems for successful intervention. These findings warrant consideration in public policy initiatives. Simply diverting individuals with these problems from the criminal justice system to the community mental health system may have limited impact unless a broader array of services can be brought to bear.     

Patient-disease characteristics and coping strategies predict hospitalization in emergency psychiatry.

OBJECTIVE: The goal of this study was to analyze how far patient-disease characteristics (sociodemographic variables, previous psychiatric treatment, way of referral, the patient's current diagnosis), and the patient's coping strategies are connected with the consecutive disposition for inpatient or outpatient treatment. METHODS: Data from a one-year intake of the psychiatric emergency service at a University Hospital (N = 1439) were monitored and analyzed with regard to the decision on treatment. Four hundred eighty-one patients were hospitalized and 530 were assigned to outpatient treatment. Two subsamples of twenty-eight patients from each group filled out the Bernese Coping Modes questionnaire before the decision with regard to the treatment disposition was taken. RESULTS: The patient's psychiatric history, the way of referral as well as the current axis I diagnosis made a significant contribution to the treatment decision. Overall, patient-disease characteristics allowed for correct classification of 69.3 percent of cases. However, coping was a comparable predictor of hospitalization. CONCLUSIONS: It is argued that the search for patient-disease characteristics in the psychiatric emergency room should be complemented by a more extensive monitoring of the patients' way of coping with their current crisis.     

Hospital based psychiatric emergency services: a guide to service delivery and clinical best practices

Hospital based psychiatric emergency services play an integral role in the initiation of mental health and psychiatric service delivery worldwide. Whenever possible, hospital based psychiatric emergency services should be delivered in accordance to best practice standards. Unfortunately, no such standards exist internationally in the case of hospital based psychiatric emergency services. This paper represents an attempt to rectify this problem. International mental health and psychiatric literature pertaining to hospital based psychiatric emergency services was reviewed and a guide to service delivery and clinical best practice was generated.     

Risperidone liquid concentrate and oral lorazepam versus intramuscular haloperidol and intramuscular lorazepam for treatment of psychotic agitation

BACKGROUND: Although agitation associated with psychosis is a common presentation in the psychiatric emergency service, there is no consensus concerning the best treatment. Standard treatment often consists of intramuscular (i.m.) injection of high-potency neuroleptics, sometimes combined with benzodiazepines. The objective of this study was to determine the relative efficacy, safety, and tolerability of oral risperidone versus intramuscular haloperidol, both in combination with lorazepam, for the emergency treatment of psychotic agitation in patients who are able to accept oral medications. METHOD: A convenience sample of psychotic patients admitted to a large psychiatric emergency service who required emergency medication for the control of agitation and/or violence was offered risperidone (2 mg liquid concentrate) and oral lorazepam (2 mg) as an alternative to standard care at the institution, haloperidol (5 mg i.m.) and lorazepam (2 mg i.m.). Subjects who refused the oral medications were given the intramuscular treatment as a component of routine care. RESULTS: Thirty patients were enrolled in each treatment group. Although men were significantly more likely to choose oral medication (chi2 = 5.165, p < .023), other demographic characteristics did not differ significantly between the 2 treatment groups. Both groups showed similar improvement in agitation as measured by 5 agitation subscales of the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impressions (CGI) scale, and time to sedation. No patients receiving risperidone demonstrated any side effects or adverse events, while 1 patient receiving intramuscular treatment with haloperidol developed acute dystonia. One subject receiving risperidone required subsequent treatment with haloperidol for ongoing agitation. CONCLUSION: Oral treatment with risperidone and lorazepam appears to be a tolerable and comparable alternative to intramuscular haloperidol and lorazepam for short-term treatment of agitated psychosis in patients who accept oral medications.     

Accuracy of psychiatric diagnosis performed under indirect supervision

This work aimed at comparing the accuracy of the psychiatric diagnoses made under indirect supervision to the diagnoses obtained through Structured Clinical Interview for DSM-III-R (SCID). The study was conducted in 3 university services (outpatient, inpatient and emergency). Data from the emergency service were collected 3 years later, after changes in the training process of the medical staff in psychiatric diagnosis. The sensitivity for Major Depression (outpatient 10.0%; inpatients 60.0%, emergency 90.0%) and Schizophrenia (44.4%; 55.0%; 80.0%) improved over time. The reliability was poor in the outpatient service (Kw = 0.18), and at admission to the inpatient service (Kw = 0.38). The diagnosis elaborated in the discharge of the inpatient service (Kw = 0.55) and in the emergency service (Kw = 0.63) was good. Systematic training of supervisors and residents in operational diagnostic criteria increased the accuracy of psychiatric diagnoses elaborated under indirect supervision, although excellent reliability was not achieved.     

The prognosis of psychiatric treatment in military service

Summary The author discusses the outcome of psychiatric treatment in the Military. He served as a military psychiatrist in Norway for one year. During this time he personally examined and treated 215 soldiers with psychiatric disorders. The diagnostic composition of the patient group and the treatment given are described. The patient material was again examined at the end of the military service period, when one-third of the patients had been found unfit for service. The remainder were still fit for service. The patients did not differ from soldiers in general from a disciplinary point of view. However, they did not achieve as good grades in personal conduct and military efficiency as the other soldiers. The patients' clinical picture at the follow-up examination had improved when compared to the initial psychiatric examination. The author concludes that psychiatric treatment in the Military is both possible and desirable.