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Psychiatric Emergencies Call for Comprehensive Assessment and Treatment

Psychiatric Emergencies Call for Comprehensive Assessment and Treatment Philadelphia—Psychiatric emergencies often erupt suddenly. A person may curse or hit others, throw objects, or brandish a weapon. The individual may announce plans to commit suicide or attempt to do so. Someone may neglect self-care and stop eating, exhibit confusion, and perhaps wander into traffic, or go outside unclothed. Those at the scene—family, friends, coworkers, perhaps strangers—can't handle the situation. They call police or an ambulance. Time of day is a factor, too. Psychiatric emergencies peak between 6 PM and 10 PM. With family members home together, long-standing conflicts may explode. Substance use, which rises in the evening, aggravates disruptive behavior. Family physicians, pastoral counselors, and other resources may be hard to reach. The incidence of psychiatric emergencies is rising, said Michael Allen, MD, who chaired a symposium on the topic at the annual meeting of the American Psychiatric Association (APA). While the US population has grown, the number of psychiatric beds in this country has steadily declined, a legacy of deinstitutionalization that began a half-century ago. Substance abuse also has soared, yet support for community mental health and substance abuse services has fallen, said Allen, who directs inpatient psychiatry at Colorado Psychiatric Health, Denver. Moreover, people with mental illnesses often lack a primary care physician and seek health care only in crises. Often uninsured, they frequently have been denied coverage because of medical illness. Managing suicide threats "It used to be that a patient talking about suicide was always hospitalized," Allen said. "Today, the patient has to come in with a gun to his head or your head to get hospitalized. Today, we have to deal with more suicidal patients in the community." At least one in three patients seen in psychiatric emergency service (PES) is thinking about or has attempted suicide, said Peter Forster, MD, director of Gateway Psychiatric Services, San Francisco, speaking at the APA symposium. Identifying individuals most at risk of suicide has proved a daunting task, Forster said. A history of a suicide attempt increases the odds of completing suicide more than any other risk factor. Follow-up 5 years later of people receiving emergency care for such attempts shows that one in six has died of suicide or accidental causes, often related to risk-taking behavior (Soc Psychiatry Psychiatr Epidemiol. 2001;36:29-35). Yet, most people who commit suicide reportedly never made a prior attempt. Most who attempt suicide never see a mental health clinician. A Finnish study found that only 22% of 571 people who saw a health care professional in the 28 days before they committed suicide had discussed their suicidal intent at that appointment. This included 100 people who ended their lives the same day as their visit. Those who saw general practitioners or other nonpsychiatrists were most likely not to have revealed their plans (Am J Psychiatry. 1995;152:919-922). People who attempt suicide once or more, and later complete the act, tend to be more anxious and socially withdrawn than those who do not kill themselves, Forster said, and they generally make more brutal attempts. About four times as many men as women commit suicide, although women attempt it twice as often as men. To assess the risk of suicide, a physician should ask, "How bad do you feel? Have you ever thought about suicide? Do you have a gun at home?" Those who have committed suicide were twice as likely to have had guns in the home as those who have attempted suicide. "Denying access to guns," Forster asserted, "prevents suicide." PES staff need to call the patient's primary health care providers, family, and often friends. Ideally they'll gain the patient's permission to make the call, Forster said, but sometimes they must breach confidentiality. Even when a patient makes suicidal ideation known, hospitalization is not always the best choice. Avoiding a disruption in outpatient treatment may prove more effective, he said, although this option presents a higher safety risk. Agitation and aggression People in crisis frequently display agitation and aggression, separate but overlapping constellations of symptoms that can arise from many different illnesses, said Martha Crowner, MD, attending psychiatrist at Manhattan Psychiatric Center, New York City. Behavioral signs of agitation include motor restlessness, irritability, jitteriness, and purposeless and repetitive motor or verbal activity. Aggression can be broadly defined—acts against others, self, or objects, plus cursing or screaming—or more narrowly defined as acts causing injury to others. Mentally ill people most commonly exhibit impulsive violence, a hair-trigger response to a stimulus that puts them in an agitated state. Violence tends to occur when people are acutely mentally ill, Crowner said. Patients may not be able or willing to give a coherent history, and family or friends may not be reachable. A physician's immediate goal, Crowner said, is to resolve the behavioral emergency, and reestablish inner and outer controls for the patient in the least coercive way. Head start on treatment A crisis often provides an opportunity for change in a patient, according to Ronald Rosenberg, MD. The crisis situation mitigates denial, avoidance, and rigidity, said Rosenberg, associate director for inpatient psychiatric services, North Shore University Hospital, Manhasset, NY. Patients may have been taken forcibly to PES by police, family, or an ambulance. Space and privacy are limited there. Physicians are rushed. But encounters still can be therapeutic, he maintained. Tuning in to the patient's emotional reactions, Rosenberg said, can help ease frustration, calm agitation, and encourage patients to talk about their concerns. Physicians should attend to immediate needs: the patient may be hungry or thirsty. One can offer choices—"Would you like this chair or that one?"—and show empathy—"This has been a hard day for you." One should strive to build an alliance before asking necessary questions that may upset the patient or sound trivial: "Have you been in jail? Can you spell ‘world' backwards?" The notion of restoring equilibrium, offering a hungry patient a sandwich, for example, Rosenberg said, is not a psychiatric model, it's a consumer model. The physician offers help, the patient sees that, and more often cooperates with treatment. Comorbidity common Medical morbidity is the "hot button" topic today, said Glenn Currier, MD, MPH, who directs PES at the University of Rochester Medical Center, Rochester, NY. A diabetic crisis or seizure may mimic a psychiatric emergency. Many medical illnesses cause or exacerbate psychiatric symptoms. More than half of all patients coming to PES may have coexisting medical problems. People with schizophrenia may be at elevated risk, he said. One study found that two in five poor, inner-city patients with this illness also had one or more medical disorders, most often hypertension, diabetes, obesity, asthma or bronchitis, seizures, or orthopedic injuries. In many emergency departments, a nurse performs triage in a central physical location, obtains a brief history, and routes patients to medical or psychiatric services. On the medical side, a patient with a broken arm may not be asked about a family history of diabetes. But PES personnel need to address concurrent medical illnesses, alcohol and drug abuse, and adverse reactions to prescription medications. The "ideal" work-up that some specialists suggest would be too time-consuming and costly to be practical, Currier said. Whether psychiatrists should perform physical examinations is still debated. Currier's suggestion that they do so prompted a question from the audience on whether patients need disrobe; only partially, he said. Psychiatric assessment in PES, Currier said, serves functions other than direct patient care. It determines whether a patient should be admitted or referred elsewhere for care, and whether a patient requires involuntary civil commitment. It also provides a definitive diagnosis so proper treatment can be started. Assessment increasingly involves use of standardized cognitive screens, such as the Trailmaking Test, which requires subjects to connect a series of numbers and letters. Comprehensive services Modern PES contains a range of services focused on keeping patients in the community or returning them there quickly. Some offer extended observation—up to 23 hours—enabling staff to hold patients overnight, start medication, and make community contacts in the morning. Short hospitalization programs, up to 5 days, located in or near a PES, can help patients with personality disorders get through a suicidal crisis and monitor patients who abused alcohol or other drugs in the immediate postintoxication period. Mobile teams can help patients who are medically and mentally ill, particularly those who don't want to see a psychiatrist. Some areas have established crisis residences for short-term stays of up to 1 week; oversight of such facilities is still evolving. "If I were a primary care physician," symposium chair Allen said in an interview, "I wouldn't want to be confronted with a patient whose behavior is erratic and potentially dangerous and not know what to do. Community physicians need to press their local mental health agencies and hospitals to make organized PES a priority. When you need this service," he asserted, "you really need it." Box Section Ref ID Further Reading Emergency Psychiatry, edited by Michael Allen, MD, contains detailed reviews of assessment and treatment coauthored by speakers cited in this article (Washington, DC: American Psychiatric Press Inc, 2002, $31.95, http://www.appi.org/). Suicide was the eighth leading cause of death for all Americans, and the third leading cause of death for 15- to 24-year-olds in 1999. About 31 000 people kill themselves in the United States each year, 85 on average each day. For every two victims of homicide, three people take their own lives. These statistics and more information are available in The Surgeon General's Call to Action to Prevent Suicide 1999, which may be accessed at http://www.mentalhealth.org/suicideprevention/calltoaction.pdf. —L.L. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Psychiatric Emergencies Call for Comprehensive Assessment and Treatment

JAMA , Volume 288 (6) – Aug 14, 2002

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Publisher
American Medical Association
Copyright
Copyright © 2002 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.288.6.686-JMN0814-2-1
Publisher site
See Article on Publisher Site

Abstract

Philadelphia—Psychiatric emergencies often erupt suddenly. A person may curse or hit others, throw objects, or brandish a weapon. The individual may announce plans to commit suicide or attempt to do so. Someone may neglect self-care and stop eating, exhibit confusion, and perhaps wander into traffic, or go outside unclothed. Those at the scene—family, friends, coworkers, perhaps strangers—can't handle the situation. They call police or an ambulance. Time of day is a factor, too. Psychiatric emergencies peak between 6 PM and 10 PM. With family members home together, long-standing conflicts may explode. Substance use, which rises in the evening, aggravates disruptive behavior. Family physicians, pastoral counselors, and other resources may be hard to reach. The incidence of psychiatric emergencies is rising, said Michael Allen, MD, who chaired a symposium on the topic at the annual meeting of the American Psychiatric Association (APA). While the US population has grown, the number of psychiatric beds in this country has steadily declined, a legacy of deinstitutionalization that began a half-century ago. Substance abuse also has soared, yet support for community mental health and substance abuse services has fallen, said Allen, who directs inpatient psychiatry at Colorado Psychiatric Health, Denver. Moreover, people with mental illnesses often lack a primary care physician and seek health care only in crises. Often uninsured, they frequently have been denied coverage because of medical illness. Managing suicide threats "It used to be that a patient talking about suicide was always hospitalized," Allen said. "Today, the patient has to come in with a gun to his head or your head to get hospitalized. Today, we have to deal with more suicidal patients in the community." At least one in three patients seen in psychiatric emergency service (PES) is thinking about or has attempted suicide, said Peter Forster, MD, director of Gateway Psychiatric Services, San Francisco, speaking at the APA symposium. Identifying individuals most at risk of suicide has proved a daunting task, Forster said. A history of a suicide attempt increases the odds of completing suicide more than any other risk factor. Follow-up 5 years later of people receiving emergency care for such attempts shows that one in six has died of suicide or accidental causes, often related to risk-taking behavior (Soc Psychiatry Psychiatr Epidemiol. 2001;36:29-35). Yet, most people who commit suicide reportedly never made a prior attempt. Most who attempt suicide never see a mental health clinician. A Finnish study found that only 22% of 571 people who saw a health care professional in the 28 days before they committed suicide had discussed their suicidal intent at that appointment. This included 100 people who ended their lives the same day as their visit. Those who saw general practitioners or other nonpsychiatrists were most likely not to have revealed their plans (Am J Psychiatry. 1995;152:919-922). People who attempt suicide once or more, and later complete the act, tend to be more anxious and socially withdrawn than those who do not kill themselves, Forster said, and they generally make more brutal attempts. About four times as many men as women commit suicide, although women attempt it twice as often as men. To assess the risk of suicide, a physician should ask, "How bad do you feel? Have you ever thought about suicide? Do you have a gun at home?" Those who have committed suicide were twice as likely to have had guns in the home as those who have attempted suicide. "Denying access to guns," Forster asserted, "prevents suicide." PES staff need to call the patient's primary health care providers, family, and often friends. Ideally they'll gain the patient's permission to make the call, Forster said, but sometimes they must breach confidentiality. Even when a patient makes suicidal ideation known, hospitalization is not always the best choice. Avoiding a disruption in outpatient treatment may prove more effective, he said, although this option presents a higher safety risk. Agitation and aggression People in crisis frequently display agitation and aggression, separate but overlapping constellations of symptoms that can arise from many different illnesses, said Martha Crowner, MD, attending psychiatrist at Manhattan Psychiatric Center, New York City. Behavioral signs of agitation include motor restlessness, irritability, jitteriness, and purposeless and repetitive motor or verbal activity. Aggression can be broadly defined—acts against others, self, or objects, plus cursing or screaming—or more narrowly defined as acts causing injury to others. Mentally ill people most commonly exhibit impulsive violence, a hair-trigger response to a stimulus that puts them in an agitated state. Violence tends to occur when people are acutely mentally ill, Crowner said. Patients may not be able or willing to give a coherent history, and family or friends may not be reachable. A physician's immediate goal, Crowner said, is to resolve the behavioral emergency, and reestablish inner and outer controls for the patient in the least coercive way. Head start on treatment A crisis often provides an opportunity for change in a patient, according to Ronald Rosenberg, MD. The crisis situation mitigates denial, avoidance, and rigidity, said Rosenberg, associate director for inpatient psychiatric services, North Shore University Hospital, Manhasset, NY. Patients may have been taken forcibly to PES by police, family, or an ambulance. Space and privacy are limited there. Physicians are rushed. But encounters still can be therapeutic, he maintained. Tuning in to the patient's emotional reactions, Rosenberg said, can help ease frustration, calm agitation, and encourage patients to talk about their concerns. Physicians should attend to immediate needs: the patient may be hungry or thirsty. One can offer choices—"Would you like this chair or that one?"—and show empathy—"This has been a hard day for you." One should strive to build an alliance before asking necessary questions that may upset the patient or sound trivial: "Have you been in jail? Can you spell ‘world' backwards?" The notion of restoring equilibrium, offering a hungry patient a sandwich, for example, Rosenberg said, is not a psychiatric model, it's a consumer model. The physician offers help, the patient sees that, and more often cooperates with treatment. Comorbidity common Medical morbidity is the "hot button" topic today, said Glenn Currier, MD, MPH, who directs PES at the University of Rochester Medical Center, Rochester, NY. A diabetic crisis or seizure may mimic a psychiatric emergency. Many medical illnesses cause or exacerbate psychiatric symptoms. More than half of all patients coming to PES may have coexisting medical problems. People with schizophrenia may be at elevated risk, he said. One study found that two in five poor, inner-city patients with this illness also had one or more medical disorders, most often hypertension, diabetes, obesity, asthma or bronchitis, seizures, or orthopedic injuries. In many emergency departments, a nurse performs triage in a central physical location, obtains a brief history, and routes patients to medical or psychiatric services. On the medical side, a patient with a broken arm may not be asked about a family history of diabetes. But PES personnel need to address concurrent medical illnesses, alcohol and drug abuse, and adverse reactions to prescription medications. The "ideal" work-up that some specialists suggest would be too time-consuming and costly to be practical, Currier said. Whether psychiatrists should perform physical examinations is still debated. Currier's suggestion that they do so prompted a question from the audience on whether patients need disrobe; only partially, he said. Psychiatric assessment in PES, Currier said, serves functions other than direct patient care. It determines whether a patient should be admitted or referred elsewhere for care, and whether a patient requires involuntary civil commitment. It also provides a definitive diagnosis so proper treatment can be started. Assessment increasingly involves use of standardized cognitive screens, such as the Trailmaking Test, which requires subjects to connect a series of numbers and letters. Comprehensive services Modern PES contains a range of services focused on keeping patients in the community or returning them there quickly. Some offer extended observation—up to 23 hours—enabling staff to hold patients overnight, start medication, and make community contacts in the morning. Short hospitalization programs, up to 5 days, located in or near a PES, can help patients with personality disorders get through a suicidal crisis and monitor patients who abused alcohol or other drugs in the immediate postintoxication period. Mobile teams can help patients who are medically and mentally ill, particularly those who don't want to see a psychiatrist. Some areas have established crisis residences for short-term stays of up to 1 week; oversight of such facilities is still evolving. "If I were a primary care physician," symposium chair Allen said in an interview, "I wouldn't want to be confronted with a patient whose behavior is erratic and potentially dangerous and not know what to do. Community physicians need to press their local mental health agencies and hospitals to make organized PES a priority. When you need this service," he asserted, "you really need it." Box Section Ref ID Further Reading Emergency Psychiatry, edited by Michael Allen, MD, contains detailed reviews of assessment and treatment coauthored by speakers cited in this article (Washington, DC: American Psychiatric Press Inc, 2002, $31.95, http://www.appi.org/). Suicide was the eighth leading cause of death for all Americans, and the third leading cause of death for 15- to 24-year-olds in 1999. About 31 000 people kill themselves in the United States each year, 85 on average each day. For every two victims of homicide, three people take their own lives. These statistics and more information are available in The Surgeon General's Call to Action to Prevent Suicide 1999, which may be accessed at http://www.mentalhealth.org/suicideprevention/calltoaction.pdf. —L.L.

Journal

JAMAAmerican Medical Association

Published: Aug 14, 2002

Keywords: psychiatric emergencies,suicide

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