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.     

Homebound aged: the dilemma of psychiatric intervention

This study reports the 12 month experience of a hospital-based, multidisciplinary psychogeriatric community team. The patients evaluated were unable to come to the hospital clinics because of a psychiatric and/or physical disability. The group included some patients rarely seen in psychiatric office practice and outpatient facilities, but who posed problems for their families and the community. Some required referral to a clinic, crisis management or emergency hospitalization. Others however, required only minimal intervention. A total of 151 patients (119 females and 32 males) whose average age was 78.2, were seen. Seventy percent were widowed, single, divorced or separated; 43% lived alone. The patients were grouped according to the method of intervention used: psychiatric and social intervention--55%; social and nursing intervention--28%; no follow-up--11% and; emergency hospitalization--6%. Seventeen patients were left "untreated". These patients usually had more adequate family or community support than was initially apparent. They were referred for a crisis which was resolved quickly. An attempt is made to explain our approach, and several case examples are given.     

Economic impact of crisis intervention in emergency psychiatry: a naturalistic study

OBJECTIVE: This is a naturalistic study comparing the outcomes of all emergency psychiatric interventions in the Hospital Center of Luxembourg during two periods of six months each, before and after the introduction of a crisis intervention program. The aim of the study was to investigate the clinical and economic impact of crisis intervention on psychiatric emergency admissions. METHODS: All subjects admitted to the emergency psychiatric unit during the two study periods were considered for participation. Data were collected retrospectively and comparisons were made between patients before (September 1, 2001 to February 28, 2002) and after (September 1, 2002 to February 28, 2003) crisis intervention programs were established. RESULTS: A comparison between the two patient groups demonstrated a significant decrease in the rate of voluntary hospitalizations after crisis intervention, and a significant increase in the number of patients with subsequent outpatient consultations. The cost increase due to ambulatory follow-ups was widely compensated for by the cost decrease due to hospitalization avoidance. CONCLUSIONS: These preliminary findings suggest that crisis intervention leads to a shift from hospitalization to outpatient psychotherapeutic management in emergency psychiatric services, which has a significant economic impact.     

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.     

Elders of 75 and over at an emergency service

Context: Elderly patients represent an important and growing part of the emergency department activity. Purpose: To describe population aged of 75?and over admitted in an emergency department without programming and then compare patients addressed with a letter of referral or not. Methods: A prospective transversal study was carried out over one month in the emergency department of the hospital of Macon. It concerned all patients aged of 75?and over admitted at the emergency department. Results: The study concerned 459?passages of elders (17% of admissions during the period), among whom 40% were addressed with a letter of referral. Mean age was 83.4, with a sex-ratio of 0.6. The hospitalization rate is significantly higher among the letter addressed group: 84% vs 72% (p<0.01). The Emergency room reception of elderly people was evaluated as required for 70% of cases (essentially for medical reasons) and the family physician could have planed the hospitalization for 21% of cases. The mean duration stay was 8.6?days. The mortality at one month was 6%, without significant difference between the two groups. Readmission rate after 3?months was of 20% one more time at least during the period. Discussion: Elderly people passage through the emergency department tends to become the admission way to the hospital. An important part of these patients are addressed with a letter of referral, which does not modify the patient's orientation. Nevertheless, some could avoid emergency room passage. This report has to bring us to a reflexion about a work with the physicians to welcome in best these elders at hospital.     

A crisis triage rating scale. Brief dispositional assessment of patients at risk for hospitalization

The authors have developed a brief rating scale to expedite the rapid screening of emergency psychiatric patients who require hospital admission from those who are suitable for outpatient crisis intervention treatment. The interviewers used this scale to assess and score the patient rapidly on the basis of three factors: dangerousness, support system, and motivation or ability to cooperate. The authors report on and discuss the use of the scale in a preliminary study of 300 cases and in a prospective study of 122 patients who were followed for 6 months after they were evaluated. They found that those who scored below a median point on the scale required hospitalization and those who scored higher were suitable for crisis intervention as outpatients.     

Management of suicide attempts in Italy and Sweden. A comparison of services offered to consecutive samples of suicide attempters

The aim of the study was to compare the management of suicide attempts by patients in Sweden and Italy with a view to providing a perspective on differences in treatment. Two consecutive samples of suicide attempters from Huddinge (n=97) and Padua (n=100) were studied in terms of sociodemographic characteristics, previous care, referral, medical and psychiatric care, hospitalization, aftercare, and short-term compliance. In Italian somatic management of acute suicidal crises, there are more physicians specializing in anesthesia or internal medicine working in ambulances and emergency wards, and there is a heavier emphasis on somatic care. Swedish management procedures seem to entail more medical examinations and biohumoral tests. Moreover, the procedures at the Swedish hospital give priority to early psychiatric intervention, and admission to psychiatric inpatient care is more frequent. However, it is not normal practice in emergency psychiatric care at either of the centers for specialists to serve in the immediate liaison consultation. There are differences in assessment and treatment between the two countries that may provide a perspective on their procedures, implying that current procedures for managing patients belonging to groups identified as “high-risk” in terms of suicide may be modified.     

Characteristics of Patients Referred to Psychiatric Emergency Services by Crisis Intervention Team Police Officers

The Crisis Intervention Team (CIT) program trains police officers in crisis intervention skills and local psychiatric resources. Because the safety and appropriateness of any new intervention is a crucial consideration, it is necessary to ensure that CIT training does not result in excessive or inappropriate referrals to psychiatric emergency services (PES). Yet, aside from one prior report by Strauss et al. (2005) in Louisville, Kentucky, little is known about the comparability of patients referred to PES by CIT-trained officers in relation to other modes of referral. The research questions driving this retrospective chart review of patients referred to PES were: (1) What types of patients do CIT-trained officers refer to PES?, and (2) Do meaningful differences exist between patients referred by family members, non-CIT officers, and CIT-trained officers? Select sociodemographic and clinical variables were abstracted from the medical records of 300 patients during an eight-month period and compared by mode of referral. Differences across the three groups were found regarding: race, whether or not the patient was held on the locked observation unit, severe agitation, recent substance abuse, global functioning, and unkempt or bizarre appearance. However, there were virtually no differences between patients referred by CIT-trained and non-CIT officers. Thus, while there were some expected differences between patients referred by law enforcement and those referred by family members, CIT-trained officers appear to refer individuals appropriately to PES, as evidenced by such patients differing little from those referred by traditional, non-CIT police officers. Trained officers do not have a narrower view of people in need of emergency services (i.e., bringing in more severely ill individuals), and they do not have a broader view (i.e., bringing in those not in need of emergency services). Although CIT training does not appear to affect the type of individuals referred to PES, future research should examine the effect of CIT training on the frequency of referrals or proportion of subjects encountered that are referred, which may be expected to differ between CIT-trained and non-CIT officers.     

Major depressive disorders and psychiatric emergencies: a naturalistic study on crisis intervention relevance]

OBJECTIVE: This retrospective study aimed to evaluate the impact of introducing crisis intervention patterns in the emergency unit of a general hospital on the number of admissions and outpatient follow-ups for patients with major depressive disorder. METHOD: The study included all patients with major depressive disorder (DSM-IV criteria) who visited the psychiatric emergency unit in a general hospital during two 8-month periods: before (425 patients) and after (436 patients) crisis interventions were introduced. RESULTS: After crisis interventions were introduced, the voluntary admission rate decreased significantly (from 17.9% to 12.4%), while the number of outpatient follow-ups increased (from 82.1% to 86.2%). Borderline personality disorder was associated with a significant reduction of the admission rate (27.8% against 38.2%), while the admission rate for patients with depressive disorder with psychotic features did not decline after crisis interventions. Crisis interventions were more effective on women. CONCLUSIONS: These outcomes suggest the relevance of crisis intervention in psychiatric emergency settings to improve the management of patients with major depressive disorder. Crisis intervention fosters outpatient multimodal follow-up rather than admission in a psychiatric setting.     

Consultation Psychiatry in a Japanese General Hospital: Patients Referred to Psychiatric Consultation*

Abstract: A total of 164 (47%) out of 350 new psychiatric patients in a general hospital in Japan were those referred to psychiatric consultation. In 47% of the cases, concurrent physical and psychiatric disorders were reported. In the referred patients, neurosis (38%) was the most common psychiatric disorder, followed by other nonorganic psychoses (9%), schizophrenic psychoses (8%), alcoholic psychoses (8%), transient organic psychotic conditions (7%), affective psychoses (6%) and others. The high frequency of psychiatric emergency cases (23%) including cases with suicide attempts (12%) indicated that psychiatrists play an important role in psychiatric emergency crisis intervention in the general hospital emergency service. In suicide attempts, depression was most prominent, but schizophrenic psychoses were also involved in a third of the cases.     

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.     

Consultation psychiatry in a Japanese general hospital: patients referred to psychiatric consultation

A total of 164 (47%) out of 350 new psychiatric patients in a general hospital in Japan were those referred to psychiatric consultation. In 47% of the cases, concurrent physical and psychiatric disorders were reported. In the referred patients, neurosis (38%) was the most common psychiatric disorder, followed by other nonorganic psychoses (9%), schizophrenic psychoses (8%), alcoholic psychoses (8%), transient organic psychotic conditions (7%), affective psychoses (6%) and others. The high frequency of psychiatric emergency cases (23%) including cases with suicide attempts (12%) indicated that psychiatrists play an important role in psychiatric emergency crisis intervention in the general hospital emergency service. In suicide attempts, depression was most prominent, but schizophrenic psychoses were also involved in a third of the cases.     

Evaluation of a mobile crisis program: effectiveness, efficiency, and consumer satisfaction

OBJECTIVE: The effectiveness and efficiency of a mobile crisis program in handling 911 calls identified as psychiatric emergencies were evaluated, and the satisfaction of consumers and police officers with the program was rated. METHODS: The study retrospectively examined differences in subjects' demographic characteristics, hospitalization and arrest rates, and costs for 73 psychiatric emergency situations handled by a mobile crisis team and 58 psychiatric emergency situations handled by regular police intervention during three months in 1995. Consumers' and police officers' satisfaction with the mobile crisis program was evaluated through Likert-type scales. RESULTS: Fifty-five percent of the emergencies handled by the mobile crisis team were managed without psychiatric hospitalization of the person in crisis, compared with 28 percent of the emergencies handled by regular police intervention, a statistically significant difference. The difference in arrest rates for persons handled by the two groups was not statistically significant. The average cost per case was 23 percent less for persons served by the mobile crisis team. Both consumers and police officers gave positive ratings to the mobile crisis program. CONCLUSIONS: Mobile crisis programs can decrease hospitalization rates for persons in crisis and can provide cost-effective psychiatric emergency services that are favorably perceived by consumers and police officers.     

A mobile crisis unit in the psychiatric emergency room

A mobile psychiatric crisis intervention service based in the emergency room of a county receiving hospital sends teams into the community to screen and treat patients in crisis. The teams have been able to treat 70 percent of the patients seen in the community without hospitalization. Two-thirds of those hospitalized are admitted to nonpublic community hospitals, thus relieving the load on public institutions. To augment their work with patients, the teams employ a multisystems approach to treatment that attempts to identify and resolve problems not only within the patient's family, but also with the referring therapist and agency, and even with the crisis intervention service itself. The service has ensured its survival by paying close attention to the needs of its sponsoring institutions.     

Déploiement d’équipes mobiles à Saint-Étienne

In June 2017, the psychiatric catchment area (sector) of the city of Saint-Étienne (Loire, France) closed a full-time hospitalization unit to create a community treatment outreach team. This reorganization, which appeared necessary to both healthcare teams and direction teams of the hospital, was stirred by overwhelming presence of psychiatric users in the emergency department and difficulty in providing adequate care to the population of the catchment area. The complex situation of the city of Saint-Étienne thus proved to be an opportunity for change. The project was build according to concepts of recovery. The chosen models were assertive community treatment, intensive home monitoring, transitional case management (transition from hospital to home) and crisis intervention at home. The first observations highlighted some difficulties related to the hospitalization unit shutting, in particular because both health care providers’ staff and users relied on long-term hospitalization for rehabilitation. Many encouraging points were underlined, however. Indeed, this reorganization enabled new life project in the community for numerous patients, managing crisis without systematic requirement of hospitalization, as well as support and remobilization of the family. The first returns are both positive and promising. Thanks to a rich training program, constant exchanges with family and user associations, other unit in the sector and teams with similar experiences, the Saint-Étienne mobile psychiatry team is continuing to evolve and improve in supporting users and their families.     

Outcome of 89 psychiatric emergencies managed by 3 mental health centers in an emergency service]

This paper deals with the assessment after 2 years of the outcome of 89 psychiatric emergencies taking in charge in Saint-Luc hospital's (Brussels) emergency room, by 3 community mental health services. After the triangulation of the demand, in the emergency room, 91% of the patients go to the community mental health service. In 92.5% of cases, the crisis intervention is carried out by the same therapists they met in the emergency room with the collaboration of other members of the outpatient team. Crisis interventions are brief (less than 3 months) in 50% of cases, less than 1 years in 11.5% of cases and lead in 35% of cases to long-term in charge (more than 2 years: psychiatric and social follow-up).     

Prise en charge de la crise suicidaire

The definition of suicidal crisis extends to include different aspects starting from suicidal thoughts and ending with suicidal attempt. The management of the crisis begins at the moment of its identification and evaluation together with the exploration of the precipitating factors. This first step helps finding out the most adequate form of intervention to end the crisis, taking into consideration the moment of the crisis, the level of emergency and the nature of the crisis. The aim of this intervention is to accompany the crisis state while trying to identify the nature and the reasons of the psychical suffering of the person in order to, if possible, avoid a suicidal attempt, avoid fatal cumsequences of an attempt, avoid a new crisis and finally to help the subject survive after the crisis.