Characteristics of psychiatric emergencies and the choice of intervention strategies

The aim of this study was to describe the sociodemographic, contextual and clinical characteristics of a consecutive sample of 3611 psychiatric emergency visits to a Swiss university general hospital, and to investigate their associations with different intervention strategies. All consultations were documented by a questionnaire covering sociodemographic and diagnostic data as well as information about the consultation and the disposition decision. In a total of 1093 cases (30.3%) no further emergency intervention was required, in 1287 cases (35.6%) patients were offered out-patient crisis intervention, and in 1231 cases (34.1%) patients were hospitalized. Social integration and the presence of an easily recognizable precipitating stressor were associated with referral to out-patient crisis intervention. In logistic regression analyses, referral by the police or by health professionals (in contrast to self-referral or referral by relatives), current diagnosis of a psychotic disorder, and previous hospitalizations were the most powerful predictors of hospitalization. The presence of a precipitating stressor related to the patient's social network decreased the likelihood of hospitalization. The findings indicate a need for facilities offering brief admission, allowing for extended emergency assessments.     

Factors predicting referral to inpatient or outpatient treatment from psychiatric emergency services.

Dispositional decisions in ten psychiatric emergency rooms in New York State were examined using logistic regression. Variables influencing recommendations for inpatient or outpatient psychiatric treatment were fairly consistent across the hospitals. All terms used in the regression model were interactions formed from five variables: dangerous behavior as a reason for referral, severity of the mental disorder, the hospital where the patient presented, current signs of psychosis, and a diagnosis of major mental illness. A sixth variable, assaultive behavior in the emergency room, also influenced disposition decisions but could not be considered in the model because all patients with that characteristic were referred for inpatient treatment. A model of disposition decisions based on interactions of variables may be especially powerful because it captures the dynamic combination of factors clinicians encounter.     

Is assessing for borderline personality disorder useful in the referral after a suicide attempt?

BACKGROUND: Management of suicide attempters accounts for 10% of the psychiatric activity in the emergency room. In this population, the prevalence of borderline personality disorder (BPD) is high (10 - 55%). These patients present poorer psychosocial outcome and more frequent suicide attempts repetitions. However, the utility of the assessment of BPD in the referral to a specific treatment plan has not been yet studied. OBJECTIVE: To examine the association between the assessment of a diagnosis of BPD after a suicide attempt and the referral from the emergency room to a specific treatment plan. HYPOTHESIS: Suicide attempters with BPD, according to clinicians diagnosis, differ in terms of severity from those without more risk factors of suicide attempt repetitions and poorer psychosocial functioning, and in psychiatric referral from the emergency room. METHOD: Our case-control study took place during 10 months in the Geneva general hospital. We continuously enrolled patients admitted to the emergency room for deliberate self poisoning and separated them into two groups (BPD and control) according to the clinician's diagnosis. Data from medical records were systemically and anonymously gathered. We compared BPD patients' socio-demographic and clinical characteristics, as well as psychiatric referral, with the control group. RESULTS: Of the 478 subjects admitted to the emergency room for deliberate self-poisoning, 99 (22.6%) were diagnosed BPD by clinicians. Compared to controls, they were more frequently female (OR=3.9) and living alone (OR=3.8) and more often resorted to psychiatric care (OR=2.9), notably to emergency care (OR=3.8). Past history of suicide attempt was also more frequent (OR=1.9) as was the use of neuroleptics in the attempt (OR=2.7). No difference was detected in terms of psychiatric referral after emergency room care. CONCLUSION: Even if borderline personality disorder in suicide attempters is associated with more severity criteria, it is not associated with a referral to a specific treatment plan.     

Determination of treatment disposal for parasuicide patients in a German university hospital

Summary Within the framework of a psychiatric liaison service attached to a medical emergency unit, initial assessment, immediate crisis intervention and referral to subsequent psychiatric after-care were provided for parasuicide patients. Of a total of 485 such cases admitted in 1981, 7% were discharged without a treatment recommendation, 74% were referred to psychiatric out-patient care and 18% were admitted to psychiatric hospitals. The characteristics of these three categories of patients were compared in order to examine the criteria of treatment disposal. The characteristics found to be associated with a recommendation for psychiatric treatment included old age, previous suicidal behaviour, previous or current psychiatric treatment and a strong intent to die, as inferred from the nature and circumstances of the suicidal behaviour. Sex, addictive behaviour and severity of intoxication were of minor importance in this respect. The treatment disposition revealed a liberal interpretation of the requirements for psychiatric treatment. As regards the outcome of this strategy of care, the frequency of repeated parasuicidal behaviour, though not of completed suicide, was lower than in comparable studies reported in the literature. The implications of these findings for future evaluative research are discussed.     

Emergency psychiatric assessment of violence

OBJECTIVE: The purpose of the study was to 1) ascertain whether there are clinical and demographic characteristics that distinguish dangerous from nondangerous patients evaluated in a psychiatric emergency service and 2) identify variables that distinguish dangerous patients who are hospitalized form those who are not. METHOD: The authors conducted a case comparison study of 99 psychiatric emergency patients whom staff identified as dangerous to others, that is, violent or potentially violent. Clinical staff were interviewed and records reviewed. These data were contrasted with record review data for 95 nondangerous patients. RESULTS: Log linear analysis showed that 1) variables relating to violence in community samples--age, sex, and past history of violence--related minimally or not at all to violence in this sample and 2) disposition to hospital versus community was associated with psychotic mental status and restraint in the psychiatric emergency service. Patients requiring restraint were more likely to have recently committed assault or battery and to have been brought in by the police. CONCLUSIONS: Enduring personal characteristics of patients relate neither to psychiatric emergency service assessments of current dangerousness nor to the decision to hospitalize. These determinations appear to be related to assessments of current patient state and immediate past behavior.     

Psychiatric emergencies: an overview

The psychiatric emergency ward has become a primary entry point into the network of mental health services for people who need help to cope with their problems of living. It is also the only source of treatment for many chronically mentally ill patients living in the community. The authors critically review the literature on emergency psychiatric services, focusing on the ways these services are used, the atmosphere in the emergency room, and the determinants of disposition decision making. On the basis of their research, they suggest a model for emergency services that includes an evaluation of the patient's and his on her community's resources and competence and minimizes subtle diagnostic considerations.     

A comparison of youth referred to psychiatric emergency services: police versus other sources

Although the presentation of children and adolescents to psychiatric emergency services has been increasing, little is known about the characteristics of these persons, the circumstances surrounding their referral for treatment, or their disposition. This study compares patients referred by police with those referred by others, based on data from a study of 1,779 patients in the Bronx, New York. Logistic regression was used to develop propensity scores for selection of a matched sample of non-police referrals (n = 159) to compare with police referrals (n = 53). Caregivers in police-referred cases were rated as less capable of active treatment involvement, and domestic violence was more likely to occur in their homes. Police referrals had higher substance use in the past month than referrals from other sources, were rated as more symptomatic and dangerous to self and others, had exhibited more assaultive and destructive behavior, and were less likely to be referred to outpatient services.     

The Nordic comparative study on sectorised psychiatry: repeated emergency admissions to inpatient care during a 1-year follow-up

The emergency admissions to hospital care in six psychiatric services in four Nordic countries were explored as a part of a Nordic comparative study on sectorised psychiatry. One year treated incidence cohorts were used, with the total cohort comprising 2,454 patients. Of the 803 patients who were admitted to inpatient care during a 1-year follow-up, 82% had at least one emergency admission and 23% repeated emergency admissions. The definition for the repeated emergency admissions was at least two admissions during the follow-up. The mean length of stay in emergency inpatient care per treatment episode for this patient subgroup was 28 days. Their emergency inpatient episodes constituted 30% of all inpatient days during the follow-up. However, the variations between the services and diagnostic subgroups were large. The results of a logistic regression analysis indicated that the following variables predicted repeated emergency admissions: inpatient care at index contact, emergency outpatient contacts or no planned hospital admissions during the follow-up, psychiatric service, age under 45 years, and a diagnosis of psychosis, personality disorder or dependency. The repeated emergency admissions were related to the existence of a special service unit for abusers but not to the rates of outpatient staff or acute beds in the services, to geographical distances, referral practice or existence of emergency services.     

Attempted suicide: factors leading to hospitalization.

OBJECTIVE: This study analyzes how sociodemographic and clinical characteristics influence the treatment decision for patients referred to a university hospital emergency room (ER) owing to attempted suicide. METHOD: Using a cross-sectional design, we monitored all patients admitted to a university hospital ER after attempting suicide, over a 3-year period (n = 404). Treatment decisions were categorized into 3 groups: inpatient treatment, outpatient treatment, and no further treatment. RESULTS: Older patients were more likely to be hospitalized, while women and patients with regular occupational activity were more likely to receive outpatient treatment. In logistic regression analysis, attempted suicide using aggressive methods, history of psychiatric inpatient treatment, and psychotic disorders were associated with inpatient treatment. Adjustment and neurotic disorders were related to outpatient treatment. CONCLUSIONS: The decision to hospitalize can be satisfactorily predicted by means of sociodemographic and clinical characteristics, while the number of patients assigned to outpatient treatment is underestimated. A triage that relies only on sociodemographic and clinical data as well as risk factors could result in too frequent admissions of patients after attempted suicide.     

Predicting aftercare in psychiatric emergencies

Background Aftercare dispositions in psychiatric emergencies have often been limited to the classic armamentarium of admission vs nonadmission. It is unknown to what extent there are differences in predicting follow-up after psychiatric emergency room (PER) visits when focusing on a broader scope of aftercare possibilities. Material and methods This observational study describes and predicts aftercare dispositions after a psychiatric emergency referral: admission, onsite short-term crisis-intervention program (CIP), refusal of any aftercare, and outpatient aftercare. From March 2000 until March 2002, PER patients (N=3,719) of the university hospital were monitored regarding sociodemographic and clinical characteristics, and use of health services. Results Forty-four percent were admitted, 38% were referred to outpatient treatment, 9% refused any aftercare, and the remainder was referred to the CIP. Psychotic patients were most likely to be admitted [odds ratios (ORs) between 5.98 and 6.52], followed by patients with suicidal symptoms (OR=2.25) and those who reported outpatient service utilization (OR=1.43). Young patients (OR=3.36) or those with anxiety disorders (OR=2.03) were most likely to be referred for outpatient aftercare. Patients diagnosed with a personality disorder were at highest risk of refusing any aftercare (OR=1.81). Conclusion Despite the existence of a short-term onsite CIP, the majority of the patients were admitted after PER referral. We assume that the existence of this program decreased the number of patients who otherwise would refuse all aftercare. More research is needed in order to explain aftercare dispositions more appropriately.     

Repeated use of psychiatric emergency services by children.

In this study, the repeat utilization of child psychiatric emergency services was examined. There are patients who use psychiatric emergency services repeatedly, and these patients represent a significant proportion of child psychiatric emergencies seen in emergency rooms. Repeat patients were more likely to threaten to harm others, have a diagnosis of adjustment disorder, conduct or oppositional disorder and be under the care of a child welfare agency. They were significantly more likely than the one-time patients to be less compliant with outpatient follow-up, admitted to hospital more often, needed more social support and had greater difficulty remaining in a residential treatment setting. Intervention in the emergency room did not appear to change the way they used emergency services.     

Prediction of use of psychiatric services: application of the CART (classification and regression trees) algorithm

A computerized recursive partitioning program called Classification and Regression Trees (CART) was used to identify potential high users of services among low-income psychiatric outpatients. Sociodemographic variables, clinical variables (e.g., psychiatric diagnosis and type of presenting complaint), source of referral and the most recent psychiatric treatment setting used were studied. Discharge from inpatient psychiatric treatment right before admission to outpatient psychiatric treatment was found to be the most consistent, the most powerful and the only necessary predictor of high use of outpatient psychiatric services.     

Determinants of psychiatric hospitalization after attempted suicide

OBJECTIVE: This study investigated the characteristics of suicide attempters referred to psychiatric hospitals and the factors affecting such referral. METHOD: All 1198 consecutive suicide attempters treated in general hospital emergency rooms in Helsinki during a 12-month period were identified. Data on all health care contacts 1 year before the index attempt and on referrals to psychiatric hospitals after the attempt were gathered. RESULTS: We found that a quarter of patients were referred to psychiatric hospitals as inpatients after index suicide attempts. Factors predicting referral to psychiatric hospitals, compared to nonreferral, were older age, psychotic disorder, mood disorder, lack of alcohol consumption preceding the attempt, somatic illness, suicide attempt on a weekday, previous psychiatric treatment, psychiatric consultation and the hospital treating the suicide attempt. CONCLUSION: Although the clinical characteristics of patients attempting suicide are a major determinant of whether they are subsequently referred to psychiatric hospitals, the treatment practices of emergency room hospitals also influence treatment decisions.     

Use of coercion in psychiatric care as narrated by patients,nurses and physicians

The patterns of use of outpatient services during a 1-year follow-up in seven psychiatric services in four Nordic countries were explored as a part of a Nordic comparative study on sectorized psychiatry. One-year treated incidence cohorts were used. Three main patterns of outpatient care emerged at the service system level. First, in two of the services the outpatient care was dominated by emergency contacts. In four of the services the outpatient care was dominated by scheduled contacts, and most of the patients had no emergency outpatient contacts at all. In one of the services a remarkably large number of (38%) the patients had no outpatient contact at all. In addition to the characteristics of the psychiatric services, the following variables predicted the use of emergency outpatient services: self-referral, no inpatient care and no planned outpatient contacts during the follow-up, diagnosis of adjustment disorder or functional psychosis, and being on sick leave. The following variables predicted several scheduled outpatient contacts during the follow-up: no inpatient care and two or more emergency outpatient contacts during the follow-up, female gender, age less than 65 years, no previous inpatient care, and diagnosis of non-organic psychosis, neurosis, or personality disorder.     

Determinants of psychiatric inpatient admission to general hospital psychiatric wards: an epidemiological study in a region of central Italy

Objective: To determine which factors contribute to the decision to admit individuals to psychiatric wards in general hospitals. Method: Data on 1,379 individuals undergoing psychiatric evaluation in eight emergency rooms in a region of central Italy were collected. A logistic regression analysis was used to evaluate the likelihood of psychiatric admission considering the independent effects of demographic, social, and clinical factors and of the history of psychiatric treatment. Results: The adjusted odds ratio for psychiatric admission significantly increased with the following variables: severity of symptoms; presence of paranoid states and schizophrenic psychoses, affective psychoses and acute psychotic conditions (with neurotic disorders used as reference); a history of outpatient treatment; the presence of a staff member of a community mental health facility upon presentation at the emergency room; and the availability of beds in the psychiatric ward. Conclusion: The independent effect played by the presence of a staff member of a community mental health facility is of particular interest, suggesting the existence of a collaborative relationship between inpatient and outpatient services. Accepted: 11 December 1998     

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.     

Effects of patient and health-system characteristics on community tenure of discharged psychiatric inpatients

OBJECTIVE: The purpose of this study was to identify the differential effect of patient and health-system characteristics on length of stay in the community among recidivist psychiatric patients. METHODS: Data on demographic and clinical characteristics and mental health service utilization were collected for patients with at least one previous psychiatric hospitalization (N=1,972) who visited a psychiatric emergency department at a university hospital in Leuven, Belgium, between March 2000 and March 2002. Logistic regression analysis was used to compare the characteristics of patients with a short (less than two months), intermediate (two to 12 months), or long (12 months or longer) stay in the community between their last hospital discharge and referral to the psychiatric emergency department. RESULTS: One in three patients visited the psychiatric emergency department within 30 days of discharge from a psychiatric hospitalization, and 43 percent of the patients visited within 60 days of discharge. Patients with a short community stay were more likely to be unemployed and to have had a discharge against medical advice, a short previous hospitalization, no aftercare plan, and a history of two or more previous hospitalizations. Longer community stays were predicted by the presence of a personality disorder. CONCLUSIONS: For patients with a history of psychiatric hospitalization, early psychiatric recidivism may be more highly influenced by health-system characteristics than by the presence of severe mental illness.     

Medical and surgical inpatients who referred themselves for psychiatric consultation

Medical and surgical inpatients who referred themselves for psychiatric consultation are characterized. The 25 "self-referred" compared to 787 "others" referred to the Consultation-Liaison Psychiatry Division were more likely to state depression (52%/25%) and anxiety (36%/11%) as reasons for referral. "Self-referrals" were less likely to be referred by physicians for behavior management (8%/23%), general diagnosis (4%/22%) or suicide evaluation (4%/25%). The "self-referral" represents a challenge to the current medical model referral mechanism in which the physician controls access to consultants. The data indicate that there should be a mechanism for the patient's contribution to the referral process and that increased sensitivity to psychologic difficulties in coping with medical illness would improve the use of psychiatric consultation in the medical setting.     

Family burden and care participation: A test-retest reliability study of an interview instrument concerning families with a severely mentally ill family member

Objective: Many youngsters with mental health problems are not referred to mental health clinics. Parents play an important role in the referral process of youngster to mental health clinics. The main aim of this study was to explore the role of the parent–child relation for referral of adolescents to outpatient psychiatric clinics. Method: Employing a cross-sectional design, we compared a referred sample of 39 adolescents in outpatient psychiatric treatment with a non-referred matched control sample of 39 adolescents. The Parental Bonding Instrument and Youth Self-Report were employed to assess the characteristics of these two population groups. Results: Adolescents referred to Norwegian mental health clinics for mental health problems report more perceived care from mothers and a trend of more care from fathers compared with non-referred controls matched on level of mental health problems, age and gender. Implications of the finding for the role of parents on referral of adolescents to mental health clinics and for treatment compliance are discussed.