An integrated approach to emergency psychiatric care

Practitioner Review: Borderline personality disorder in adolescence--recent conceptualization, intervention, and implications for clinical practice

BACKGROUND

The past decade has seen an unprecedented increase in research activity on personality disorders (PDs) in adolescents. The increase in research activity, in addition to major nosological systems legitimizing the diagnosis of borderline personality disorder (BPD) in adolescents, highlights the need to communicate new research on adolescent personality problems to practitioners.

SCOPE

In this review, we provide up-to-date information on the phenomenology, prevalence, associated clinical problems, etiology, and intervention for BPD in adolescents. Our aim was to provide a clinically useful practitioner review and to dispel long-held myths about the validity, diagnostic utility, and treatability of PDs in adolescents.

FINDINGS AND CONCLUSION

Alongside providing up-to-date information on the phenomenology, prevalence, and etiology, we also report on associated clinical problems and interventions for adolescent BPD. It is only through early active assessment and identification of youngsters with these problems that a lifetime of personal suffering and health system burden can be reduced or altogether avoided. A variety of evidence-based approaches are now available to treat BPD and related clinical problems in young people. Future research should focus on establishing optimal precision in the diagnostic processes in different treatment settings.

If It Looks Like a Duck and Quacks Like a Duck: Evaluating the Validity of Borderline Personality Disorder in Adolescents

Background:

The validity of borderline personality disorder (BPD) has been a topic of much controversy in psychiatry. Over the last two decades, a wealth of empirical work has challenged long-held concerns regarding the validity of adolescent BPD. However, this research has been conducted within a traditional approach to psychiatric nosology.

Objective:

In this article, we aim to evaluate the validity of adolescent BPD as guided by both the Robins and Guze criteria for the validity of psychiatric constructs and the new National Institute of Mental Health Research Domain Criteria (NIMH RDoC).

Method:

We used the five principles of the Robins and Guze approach to evaluate selected research from our own and other groups regarding the validity of adolescent BPD. These principles include clinical description studies, laboratory studies, studies that delimitate the disorder from other related syndromes, follow-up studies, and family studies.

Results:

Within the Robins and Guze criteria framework, evidence to date supports the validity of adolescent BPD to some extent. However, limitations of the research about the construct validity of adolescent BPD have also been identified, most notably regarding the delimitation of adolescent BPD from other disorders as well as a lack of longitudinal and family studies.

Conclusions:

Given these limitations and the limitations of the Robins and Guze approach to psychiatric nosology, we recommend exploring the potential of the National Institute of Mental Health Research Domain Criteria as a complement to previous work.

A survey of emergency department psychiatric services

OBJECTIVE

The purpose of this study was to examine the methods by which emergency departments (EDs) manage clients who present with psychiatric and substance abuse issues.

METHOD

A brief survey solicited information from the ED administrators of all nonfederal acute care hospitals in two states to determine the extent to which emergency department psychiatric emergency service (EDPES) structures vary and to identify factors that influence EDPES arrangement decisions.

RESULTS

Findings confirm that significant structural variations exist, and they suggest that a hospital's decision on the management of ED psychiatric cases is associated with environmental and organizational characteristics, as well as with perceptions of the feasibility, affordability and quality of service.

CONCLUSION

Further research is needed to identify best-practice standards to enable EDPES to provide optimal patient and organizational outcomes.

[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.

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.

Psychiatric emergency services: a review of the literature and a proposed research agenda

To gain a better understanding of the scope of previous research on psychiatric emergency services (PES) and to identify areas of focus for future studies, the author reviews PES literature published between 1983 and 2003. PES literature was identified by performing a MEDLINE search. The author was interested in studies or reviews of all types of PES. The refereed research, consisting of 85 articles, is a representation of the existing literature as multiple studies were found to be similar in topic and methodology. This review is organized using Donabedian's structure, process, outcome framework to describe research that has examined 1) providers, clients, and services; 2) variations in access, utilization, evaluation, treatment, and continuity of care; and 3) outcomes of these services. The resulting report reveals methodological limitations that are pervasive throughout the PES literature, dimensions of psychiatric emergency services that remain unexplored, and a PES research agenda.

Psychiatric-Psychotherapeutic Crisis Intervention for Inpatient Adolescents

We assessed retrospectively in two periods of evaluation all inpatient crisis interventions (n1 = 75, n2 = 65) conducted in a psychiatric hospital for children and adolescents aged 13 to 19 years. In a first preliminary study we described patterns of family dynamics and developed an evaluation plan, which was used in the second study reported here. Familial conflict situations proved to be the essential factors. The adolescents' psychiatric diagnoses differed considerably from those of adult patients. Therapeutic management using a psychoanalytically oriented focal therapy and a more social-psychiatrically oriented crisis management is discussed. Data on adolescents' and families' collaboration as well as on the success of therapy are reported. It was possible to offer developmental prospects if the adolescents were able to consider their inner conflicts and if concurrently an agreement could be reached with the family. Collaboration with community health-care professionals, in particular with the appropriate social workers, was an important step in the majority of cases. Usually discharge to the home followed within a few days, in some cases to a supervised residence group. Twenty-three percent of patients required longer inpatient therapy.