Emergency psychiatry
The examples and perspective in this article deal primarily with the United States and do not represent a worldwide view of the subject. (March 2014) |
Emergency psychiatry is the clinical application of
Psychiatric emergency services are rendered by professionals in the fields of medicine, nursing, psychology and social work.[2] The demand for emergency psychiatric services has rapidly increased throughout the world since the 1960s, especially in urban areas.[3][4] Care for patients in situations involving emergency psychiatry is complex.[3]
Individuals may arrive in psychiatric emergency service settings through their own voluntary request, a referral from another health professional, or through involuntary commitment.
Care of patients requiring psychiatric intervention usually encompasses crisis stabilization of many serious and potentially life-threatening conditions which could include acute or chronic
Definition
Symptoms and conditions behind psychiatric emergencies may include
Emergency psychiatry exists to identify and/or
Delivery of services
The place where emergency psychiatric services are delivered are most commonly referred to as Psychiatric Emergency Services, Psychiatric Emergency Care Centers, or Comprehensive Psychiatric Emergency Programs.
Within a protected environment, psychiatric emergency services exist to provide brief stay of two or three days to gain a diagnostic clarity, find appropriate alternatives to psychiatric hospitalization for the patient, and to treat those patients whose symptoms can be improved within that brief period of time.[9] Even precise psychiatric diagnoses are a secondary priority compared with interventions in a crisis setting.[2] The functions of psychiatric emergency services are to assess patients' problems, implement a short-term treatment consisting of no more than ten meetings with the patient, procure a 24-hour holding area, mobilize teams to carry out interventions at patients' residences, utilize emergency management services to prevent further crises, be aware of inpatient and outpatient psychiatric resources, and provide 24/7 telephone counseling.[10]
History
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Since the 1960s, the demand for emergency psychiatric services has endured a rapid growth due to
Emergency psychiatry has involved the evaluation and treatment of unemployed, homeless and other disenfranchised populations. Emergency psychiatry services have sometimes been able to offer accessibility, convenience, and anonymity.[3] While many of the patients who have used psychiatric emergency services shared common sociological and demographic characteristics, the symptoms and needs expressed have not conformed to any single psychiatric profile.[12] The individualized care needed for patients utilizing psychiatric emergency services is evolving, requiring an always changing and sometimes complex treatment approach.[3]
Scope
Suicide attempts and suicidal thoughts
As of 2000, the World Health Organization estimated one million suicides in the world each year.[13] There are countless more suicide attempts. Psychiatric emergency service settings exist to treat the mental disorders associated with an increased risk of suicide or suicide attempts. Mental health professionals in these settings are expected to predict acts of violence patients may commit against themselves (or others), even though the complex factors leading to a suicide can stem from many sources, including psychosocial, biological, interpersonal, anthropological, and religious. These mental health professionals will use any resources available to them to determine risk factors, make an overall assessment, and decide on any necessary treatment.[2]
Violent behavior
Aggression can be the result of both internal and external factors that create a measurable activation in the autonomic nervous system. This activation can become evident through symptoms such as the clenching of fists or jaw, pacing, slamming doors, hitting palms of hands with fists, or being easily startled. It is estimated that 17% of visits to psychiatric emergency service settings are homicidal in origin and an additional 5% involve both suicide and homicide.[14] Violence is also associated with many conditions such as acute intoxication, acute psychosis, paranoid personality disorder, antisocial personality disorder, narcissistic personality disorder and borderline personality disorder. Additional risk factors have also been identified which may lead to violent behavior. Such risk factors may include prior arrests, presence of hallucinations, delusions or other neurological impairment, being uneducated, unmarried, etc.[2] Mental health professionals complete violence risk assessments to determine both security measures and treatments for the patient.[2]
Psychosis
Patients with
An individual could also be experiencing an acute onset of psychosis. Such conditions can be prepared for diagnosis by obtaining a medical or psychopathological history of a patient, performing a mental status examination, conducting psychological testing, obtaining neuroimages, and obtaining other neurophysiologic measurements. Following this, the mental health professional can perform a differential diagnosis and prepare the patient for treatment. As with other patient care considerations, the origins of acute psychosis can be difficult to determine because of the mental state of the patient. However, acute psychosis is classified as a medical emergency requiring immediate and complete attention. The lack of identification and treatment can result in suicide, homicide, or other violence.[3]
Substance dependence, abuse and intoxication
Another common cause of psychotic symptoms is substance intoxication. These acute symptoms may resolve after a period of observation or limited psychopharmacological treatment. However the underlying issues, such as substance dependence or abuse, is difficult to treat in the emergency department, as it is a long term condition.[citation needed] Both acute alcohol intoxication as well as other forms of substance abuse can require psychiatric interventions.[2][3] Acting as a depressant of the central nervous system, the early effects of alcohol are usually desired for and characterized by increased talkativeness, giddiness, and a loosening of social inhibitions. Besides considerations of impaired concentration, verbal and motor performance, insight, judgment and short-term memory loss which could result in behavioral change causing injury or death, levels of alcohol below 60 milligrams per deciliter of blood are usually considered non-lethal. However, individuals at 200 milligrams per deciliter of blood are considered grossly intoxicated and concentration levels at 400 milligrams per deciliter of blood are lethal, causing complete anesthesia of the respiratory system.[3]
Beyond the dangerous behavioral changes that occur after the consumption of certain amounts of alcohol, idiosyncratic intoxication could occur in some individuals even after the consumption of relatively small amounts of alcohol. Episodes of this impairment usually consist of confusion, disorientation, delusions and visual
Patients may also be treated for substance abuse following the
Hazardous drug reactions and interactions
Overdoses, drug interactions, and dangerous reactions from psychiatric medications, especially antipsychotics, are considered psychiatric emergencies. Neuroleptic malignant syndrome is a potentially lethal complication of first or second generation antipsychotics.[11] If untreated, neuroleptic malignant syndrome can result in fever, muscle rigidity, confusion, unstable vital signs, or even death.[11] Serotonin syndrome can result when selective serotonin reuptake inhibitors or monoamine oxidase inhibitors mix with buspirone.[2] Severe symptoms of serotonin syndrome include hyperthermia, delirium, and tachycardia that may lead to shock. Often patients with severe general medical symptoms, such as unstable vital signs, will be transferred to a general medical emergency department or medicine service for increased monitoring.[citation needed]
Personality disorders
Disorders manifesting dysfunction in areas related to cognition, affectivity, interpersonal functioning and impulse control can be considered personality disorders.[15] Patients with a personality disorder will usually not complain about symptoms resulting from their disorder. Patients with an emergency phase of a personality disorder may showcase combative or suspicious behavior, have brief psychotic episodes, or be delusional. Compared with outpatient settings and the general population, the prevalence of individuals with personality disorders in inpatient psychiatric settings is usually 7–25% higher. Clinicians working with such patients attempt to stabilize the individual to their baseline level of function.[2]
Anxiety
Patients with an extreme case of anxiety may seek treatment when all support systems have been exhausted and they are unable to bear the anxiety. Feelings of anxiety may present in different ways from an underlying medical illness or psychiatric disorder, a secondary functional disturbance from another psychiatric disorder, from a primary psychiatric disorder such as panic disorder or generalized anxiety disorder, or as a result of stress from such conditions as adjustment disorder or post-traumatic stress disorder. Clinicians usually attempt to first provide a "safe harbor" for the patient so that assessment processes and treatments can be adequately facilitated.[3] The initiation of treatments for mood and anxiety disorders are important as patients with anxiety disorders have a higher risk of premature death.[2]
Disasters
Due to the typically disorganized and hazardous environment following a disaster, mental health professionals typically assess and treat patients as rapidly as possible. Unless a condition is threatening life of the patient, or others around the patient, other medical and basic survival considerations are managed first. Soon after a disaster clinicians may make themselves available to allow individuals to ventilate to relieve feelings of isolation, helplessness and vulnerability. Dependent upon the scale of the disaster, many victims may develop either chronic or acute post-traumatic stress disorder. Patients affected severely by this disorder often are admitted to psychiatric hospitals to stabilize the individual.[3]
Abuse
Incidents of physical abuse, sexual abuse or rape can result in dangerous outcomes to the victim of the criminal act. Victims may have extreme anxiety, fear, helplessness, confusion, eating or sleeping disorders, hostility, guilt and shame. Managing the response usually encompasses coordinating psychological, medical and legal considerations. Dependent upon legal requirements in the region, mental health professionals may be required to report criminal activity to a police force. Mental health professionals will usually gather identifying data during the initial assessment and refer the patient, if necessary, to receive medical treatment. Medical treatment may include a physical examination, collection of medicolegal evidence, and determination of the risk of pregnancy, if applicable.[3]
Treatment
Treatments in psychiatric emergency service settings are typically transitory in nature and only exist to provide dispositional solutions and/or to stabilize life-threatening conditions.[3] Once stabilized, patients with chronic conditions may be transferred to a setting which can provide long term psychiatric rehabilitation.[3] Prescribed treatments within the emergency service setting vary dependent upon the patient's condition.[16] Different forms of psychiatric medication, psychotherapy, or electroconvulsive therapy may be used in the emergency setting.[16][17][18] The introduction and efficacy of psychiatric medication as a treatment option in psychiatry has reduced the utilization of physical restraints in emergency settings, by reducing dangerous symptoms resulting from acute exacerbation of mental illness or substance intoxication.[17]
Medications
With time as a critical aspect of emergency psychiatry, the rapidity of effect is an important consideration.
The amount of time required for absorption varies dependent upon many factors including drug
Psychotherapy
Other treatment methods may be used in psychiatric emergency service settings.
ECT
Observation and collateral information
There are other essential aspects of emergency psychiatry: observation and collateral information. The observation of the patient's behavior is an important aspect of emergency psychiatry as it allows the clinicians working with the patient to estimate prognosis and improvements/declines in condition. Many jurisdictions base involuntary commitment on dangerousness or the inability to care for one's basic needs. Observation for a period of time may help determine this. For example, if a patient who is committed for violent behavior in the community, continues to behave in an erratic manner without clear purpose, this will help the staff decide that hospital admission may be needed.
Collateral information or parallel information is information obtained from family, friends or treatment providers of the patient. Some jurisdictions require consent from the patient to obtain this information while others do not. For example, with a patient who is thought to be paranoid about people following him or spying on him, this information can be helpful discern if these thoughts are more or less likely to be based in reality. Past episodes of suicide attempts or violent behavior can be confirmed or disproven.
Disposition
Patient receive emergency services often on a time limited basis such as 24 or 72 hours. After this time, and sometimes earlier, the staff must decide the next place for the patient to receive services. This is referred to as disposition. This is one of the essential features of emergency psychiatry.
Hospital admission
The staff will need to determine if the patient needs to be admitted to a psychiatric inpatient facility or if they can be safely discharged to the community after a period of observation and/or brief treatment.[
Involuntary commitment
Referrals and voluntary hospitalization
In some locations, such as the United States, voluntary hospitalizations are outnumbered by involuntary commitments partly due to the fact that insurance tends not to pay for hospitalization unless an imminent danger exists to the individual or community. In addition, psychiatric emergency service settings admit approximately one third of patients from assertive community treatment centers.[2] Therefore, patients who are not admitted will be referred to services in the community.
See also
- Betty Pfefferbaum, psychiatrist, mental health treatment for children after a disaster
- Medically indigent adult
- Mental health first aid
References
- ^ a b Currier, G.W. New Developments in Emergency Psychiatry: Medical, Legal, and Economic. (1999). San Francisco: Jossey-Bass Publishers.
- ^ a b c d e f g h i j k l m n o p q r Hillard, R. & Zitek, B. (2004). Emergency Psychiatry. New York: McGraw-Hill.
- ^ a b c d e f g h i j k l m n o Bassuk, E.L. & Birk, A.W. (1984). Emergency Psychiatry: Concepts, Methods, and Practices. New York: Plenum Press.
- ^ a b Lipton, F.R. & Goldfinger, S.M. (1985). Emergency Psychiatry at the Crossroads. San Francisco: Jossey-Bass Publishers.
- ^ a b De Clercq, M.; Lamarre, S.; Vergouwen, H. (1998). Emergency Psychiatry and Mental Health Policty: An International Point of View. New York: Elsevier.
- ^ "Glossary". U.S. News & World Report. Retrieved 2007-07-15.
- ^ "Crisis Service". NAMI-San Francisco. Archived from the original on 2007-07-10. Retrieved 2007-07-15.
- PMID 12676426. Retrieved 4 Oct 2020.
- ^ Allen, M.H. (1995). The Growth and Specialization of Emergency Psychiatry. San Francisco: Jossey-Bass Publishers.
- ^ Hillard, J.R. (1990). Manual of Clinical Emergency Psychiatry. Washington D.C.: American Psychiatric Press
- ^ a b c d e f g h i j k Hedges, D. & Burchfield, C. (2006). Mind, Brain, and Drug: An Introduction to Psychopharmacology. Boston: Pearson Education.
- PMID 6986089.
- ^ "Suicide prevention (SUPRE)". World Health Organization. Archived from the original on 2004-07-01. Retrieved 2007-08-11.
- PMID 8937907.
- ^ American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition. Washington D.C.: American Psychiatric Publishing.
- ^ a b Walker, J.I. (1983) Psychiatric Emergencies. Philadelphia: J.B. Lippincott.
- ^ a b c d e f g h i j Rund, D.A, & Hutzler, J.C. (1983). Emergency Psychiatry. St. Louis: The C.V. Mosby Company.
- ^ a b Potter, M. (2007, May 31). Setting the Standards: Human Rights and Health – Mental Health Archived 2012-04-22 at the Wayback Machine. Northern Ireland Human Rights Commission.
- PMID 7023829.
- PMID 22461918.
- PMID 18647402.
Further reading
- Nurius P.S. (1983). "Emergency psychiatric services: a study of changing utilization patterns and issues". International Journal of Psychiatry in Medicine. 13 (3): 239–254. S2CID 34596811.
- Otong-Antai, D. (2001). Psychiatric Emergencies. Eau Claire: PESI Healthcare.
- Sanchez, Federico, (2007), "Suicide Explained, A Neuropsychological Approach."
- Fishkind, AB. (2002)" Calming Agitation with Words, not Drugs: 10 Commandments for Safety"
- Glick RL, Berlin JS, Fishkind AB, Zeller SL (2008) "Emergency Psychiatry: Principles and Practice." Baltimore: Lippincott Williams & Wilkins
- Zeller SL. Treatment of psychiatric patients in emergency settings. Primary Psychiatry 2010;17:35–41 http://www.primarypsychiatry.com/aspx/articledetail.aspx?articleid=2675
External links
- American Association for Emergency Psychiatry
- ATSDR - Psychological Responses to Hazardous Substances U.S. Department of Health and Human Services(public domain)
- Japanese Association of Emergency Psychiatry