Psychiatric decision making in the emergency room: a research overview

In an overview of the research on psychiatric decision making in the emergency room, the authors discuss studies done between 1963 and 1977, which suffered from an overreliance on univariate statistical techniques, problems with the reliability and validity of the instruments used for data collection, and the lack of alternatives to hospitalization for emergency room patients. More recent studies of emergency room decision making are then reviewed, with particular attention to those that had multivariate statistical designs. The article concludes with a synthesis of the research findings to date and recommends multivariate approaches and choices of variables for future studies.     

Psychiatric case-identification in an elderly urban population

Summary As part of a field-study of mental disorders in an elderly population, a random sample of over-65 year old residents of seven selected districts of Mannheim, Federal Republic of Germany, were examined using a standard method, the Clinical Psychiatric Interview Schedule, adapted for this purpose. A preliminary analysis has been carried out on data for 312 elderly community residents and for 30 elderly psychiatric hospital patients, admitted from the survey districts. The frequency distribution for a weighted total item-score conforms to a typical skewed unimodal curve. There is no evidence of a natural division between mentally ill and mentally healthy sections of the elderly population. Using an operational case-definition based on three interrelated clinical criteria, a frequency rate for all forms of psychiatric disorder of 24.0% was obtained. The results of a cluster analysis provided some support for the clinical procedure in case-identification as well as for the main diagnostic groupings. In a further analysis, the sample was allocated to sub-groups defined by 1. psychiatric status, 2. physical health and capacity for self-care and 3. type of living-group, as a first step towards estimating the need for various types of special service in the elderly population.     

Nurses as psychiatric consultants in a general hospital emergency room

Psychiatric nurses' experience in milieu therapy, home treatment, community aftercare, and psychotherapy can be the basis for new roles in mental health. This study used psychiatric nurses as consultants to general physicians in a general hospital emergency room. Psychiatric nurses successfully managed 66% of the psychiatric referrals in the emergency room and required only telephone consultation in a majority of the remaining cases to develop and implement a satisfactory treatment plan. The resistance to using nurses in this new role seems a result of anxiety generated in the emergency room staff and physicians. Sensitivity to these discomforts reduces “undermining” behavior and provides the opportunity for new roles to develop, be defined, and be accepted.     

Accidental and homicidal death in a psychiatric emergency room population

To identify potentially preventable mortality other than suicide among psychiatric emergency room patients, the authors compared the rates of accidental and homicidal death among 5,284 consecutive psychiatric emergency room patients with those expected for an age-, sex-, and race-matched sample of the general population. The rate of accidental death was two and one-half times and the rate of homicidal death nearly twice the expected rate for the matched general population. Diagnostic and demographic analyses indicated that increased risk of death from either cause was highest among alcoholics, schizophrenic patients, and males. The implications of the findings for clinical care are discussed.     

Psychiatric consultation for the geriatric population in the general hospital.

The first part of this paper is based on a study by the author in 1975--1976. The conclusions were that liaison psychiatry with geriatric patients differs from that with other age groups in the following ways: (1) referrals occur primarily when behavior becomes disturbing; (2) organic causes are often overrated but psychological and social causes and functional disorders are underestimated; (3) psychopharmaceutical agents and vasodilators are overused, while psychotherapy and other forms of treatment are underutilized. Attitudes towards consultations among these patients, their families and consultees do not differ from those of younger groups. Liaison psychiatry with a situation-oriented approach is well suited to the needs of all concerned. Review of the psychosomatic parameters of aging is summarized as a basis of the proposed psychosomatic differential model for management.     

Excessive daytime sleepiness in Campo Grande general population,Brazil

The prevalence of excessive daytime sleepiness (EDS) in general population was determined by means of 408 home interviews of adults, in a representative sample of Campo Grande city, Brazil. The random sample was stratified by sex, age and economic social status. EDS was considered in those with indexes 11 or more in the Epworth Sleepiness Scale. Statistics used chi-square, Fisher and Pearson tests; and inferences based on binomial distribution parameters; the significance level was 5% and confidence interval (CI) was 95%. The prevalence of EDS was 18.9% of the general population ( SD=1.9%; CI 15.1% to 22.7%). No significant association was found between EDS and the use of hypnotics, nor with insomnia, body mass index, sex, age, years of schooling, economic social status, marital status, occupation and the use of alternative means to improve sleep. When the sample was separated according to sex, only the male group showed significant association between EDS and actual insomnia (p=0.005).     

Psychiatric emergencies in prehospital emergency medical systems: a prospective comparison of two urban settings

BACKGROUND: Psychiatric emergency situations (PES) are of high importance to the German prehospital physician-based emergency medical system. So far, however, no prospective studies regarding the incidence of PES have been performed, neither have effects of training programs on diagnostic and therapeutic accuracy been studied. METHOD: The protocols of two emergency medical services (EMS) were collected and analyzed prospectively. Emergency physicians (EPs) in Kaiserslautern (KL) attended a standardized educational program and underwent daily supervision. EPs in Homburg (HOM) had not been informed about the study. In KL, sociodemographic variables were collected. An investigator who was not involved in the individual EMS mission assessed the correct classification of PES. RESULTS: Among all calls for an EP, 11.8% were classified as PES. There was no difference between the two centers. Correct classification of PES in KL was significantly higher than that in HOM (94.3% vs. 80.6%). Documentation of suicidal behavior was deficient in both centers. EPs in KL gave verbal crisis intervention significantly more often, administered less medication overall, and dispensed more specific drugs in psychotic disorders and significantly less drugs in substance abuse disorders. Patients were more often treated at the scene and were less often transported to a hospital. Some sociodemographic variables were associated with psychiatric morbidity of treatment. CONCLUSION: Accounting for 12% of all missions, psychiatric emergencies are a frequent reason for calls for EPs, equaling trauma-related and neurological emergencies. The most frequent reasons for calls were alcohol intoxication, states of agitation and suicidal behavior. The diagnostic and therapeutic accuracy of EPs may be improved with a concise standardized teaching program.     

Psychiatric illness in homicide victims.

The authors studied the demographic characteristics and history of psychiatric treatment of 214 homicide victims and 67 suicide victims. Thirty-two (15%) of the homicide victims and 12 (18%) of the suicide victims had a record of psychiatric care; these rates were higher than the treatment rate of the general population. The authors suggest that there may be a connection between the occurrence of homicide and the increased frequency of psychiatric disorders among victims of this crime.     

Determinants of emergency room visits for psychological problems in a general hospital

Determinants of emergency room visits for psychological reasons were studied prospectively for a four month period in an Indian General Hospital. Psychiatric emergencies constituted only 2% of all emergency visits. Most of the patients were new except for 7.4% who were already registered with the outpatient services of the psychiatry department. Males outnumbered females in a ratio of 2:1. Self-referrals constituted 77% of the samples; 21% of patients were brought by police. Two-thirds of the patients were brought owing to the severity of their clinical condition and the rest, one-third, for medico-legal and social reasons. Approximately 80% of the patients sought consultation within one month of the onset of illness episode. First episode of mental illness was within last one year of the emergency room visit in 60% patients. Past history of hospitalization for mental illness was obtained only in 10% of cases. The pattern suggested that there was no misuse of emergency services by psychiatric patients although 20% of the patients presented with social problems only which required social rather than psychiatric intervention.