Brazilian Psychiatric Association Consensus on the physical structure and ideal team for psychiatric emergencies services

INTRODUCTION

An integral part of Brazil's public health system, the psychiatric emergency service (PES) has been instrumental in improving qualified support for crisis situations of mental disorders, equitable, universally accessible, and humanized. The purpose of this article is to present a systematic review and consensus about the physical area and facilities, and ideal team qualified for psychiatric emergencies services on both Brazilian settings.

METHODS

The authors conducted a literature search using electronic databases such as MEDLINE (PubMed), Scielo, the Cochrane Database, and documents from the WHO, the Brazilian Ministry of Health, and others deemed relevant by experts. A total of 6839 manuscripts were found, but only 46 were selected. The analysis of article content summarizes consensus statements using the Delphi method and a series of interactive versions to provide a final report.

RESULTS

Changes to PES are evaluated considering various experiences and models. The authors highlighted that The Emergency Care Network (ECN) must be coordinated with qualified management, effective implementation of integration of all health equipment's and units. PES must have adequate infrastructure; qualified staff, including a psychiatrist; sufficient consultation and observational spaces; tools and resources for differential diagnosis; training for all staff members; and communication with the health care network to facilitate referrals following patient discharge are all necessary.

CONCLUSION

These standardized models need to be available to public health managers so that they can guide the installation of new services and adjust the existing ones, always looking for improvement. The authors propose requirements for PES as a model to be passed over.

Patient Flow and Reutilization of Crisis Services Within 30 Days in a Comprehensive Crisis System

OBJECTIVE

Crisis services are undergoing an unprecedented expansion in the United States, but research is lacking on crisis system design. This study describes how individuals flow through a well-established crisis system and examines factors associated with reutilization of such services.

METHODS

This cross-sectional study used Medicaid claims to construct episodes describing the flow of individuals through mobile crisis, specialized crisis facility, emergency department, and inpatient services. Claims data were merged with electronic health record (EHR) data for the subset of individuals receiving care at a crisis response center. A generalized estimating equation was used to calculate adjusted odds ratios for demographic, clinical, and operational factors associated with reutilization of services within 30 days of an episode's end point.

RESULTS

Of 41,026 episodes, most (57.4%) began with mobile crisis services or a specialized crisis facility rather than the emergency department. Of the subset (N=9,202 episodes) with merged EHR data, most episodes (63.3%) were not followed by reutilization. Factors associated with increased odds of 30-day reutilization included Black race, homelessness, stimulant use, psychosis, and episodes beginning with mobile crisis services or ending with inpatient care. Decreased odds were associated with depression, trauma, and involuntary legal status. Most (59.3%) episodes beginning with an involuntary legal status ended with a voluntary status.

CONCLUSIONS

Crisis systems can serve a large proportion of individuals experiencing psychiatric emergencies and divert them from more restrictive and costly levels of care. Understanding demographic, clinical, and operational factors associated with 30-day reutilization may aid in the design and implementation of crisis systems.

The characteristics of elderly suicidal attempters in the emergency department in Korea: a retrospective study

BACKGROUND

Although Korea ranks first in the suicide rate of elderly individuals, there is limited research on those who attempt suicide, with preventive measures largely based on population-based studies. We compared the demographic and clinical characteristics of elderly individuals who attempted suicide with those of younger adults who visited the emergency department after suicide attempts and identified the factors associated with lethality in the former group.

METHODS

Individuals who visited the emergency department after a suicide attempt from April 1, 2017, to January 31, 2020, were included. Participants were classified into two groups according to age (elderly, ≥65 years; adult, 18-64 years). Among the 779 adult patients, 123 were elderly. We conducted a chi-square test to compare the demographic and clinical features between these groups and a logistic regression analysis to identify the risk factors for lethality in the elderly group.

RESULTS

Most elderly participants were men, with no prior psychiatric history or suicide attempts, and had a higher prevalence of underlying medical conditions and attributed their attempts to physical illnesses. Being sober and planning suicide occurred more frequently in this group. In the elderly group, factors that increased the mortality rate were biological male sex (p<0.05), being accompanied by family members (p<0.05), and poisoning as a suicide method (p<0.01).

CONCLUSION

Suicide attempts in elderly individuals have different characteristics from those in younger adults and are associated with physical illness. Suicides in the former group are unpredictable, deliberate, and fatal. Therefore, tailored prevention and intervention strategies addressing the characteristics of those who are elderly and attempt suicide are required.

Longitudinal Outcomes of the top 20 Utilizers of VA Connecticut's Psychiatric Emergency Services Between 2010 and 2020

Frequent utilizers of emergency services represent a clinically important cohort with potentially unmet health care needs despite demanding a high volume of costly services. However, not much is known about their longitudinal course. This study identified the top 20 utilizers of VA Connecticut's psychiatric emergency services and conducted a chart review of their longitudinal outcomes during an 11-year period between 2010 and 2020, including their visit diagnoses, medical and psychiatric comorbidities, and types and frequency of other medical services and supports received. At the index visit, 19 of the 20 patients had substance use disorder and 14 patients had at least one non-substance psychiatric diagnosis. Despite all patients receiving primary care and other services, such as residential treatments, outpatient therapy, and social work consults, 11 of the 12 patients remaining alive and residing in the state continued to utilize psychiatric emergency services in 2020, revealing a pattern of persistent use.

Psychiatric emergencies among urban youth during COVID-19: Volume and acuity in a multi-channel program for the publicly insured

This study sought to characterize changes in the utilization of psychiatric emergency services among children and adolescents during distinct phases of 2020, as compared with prior years. We conducted a retrospective review of electronic health records from January 2018 through December 2020 that included all encounters made by patients under age 21. We then analyzed data for the 15,045 youth psychiatric encounters during the study period. Encounter volume in 2020 was significantly lower than prior years in March through May (IRR, 0.44; 95% CI, 0.40-0.49), May through July (IRR, 0.63; 95% CI, 0.56-0.71), and October through December (IRR, 0.76; 95% CI, 0.70-0.83). Encounters for youth with primary psychotic disorders remained at typical levels throughout 2020. Among older adolescents and youth with anxiety disorders, pervasive developmental disorders, and substance use disorders, encounter volume was significantly lower than prior years only during the initial lockdown period. There were significantly more encounters than normal conducted by mobile crisis units, including via telehealth, in July through October (IRR, 1.31; 95% CI, 1.06-1.62) and October through December (IRR, 1.28; 95% CI, 1.05-1.55) of 2020. Differences in patterns of encounter volume based on sociodemographic and clinical characteristics highlight subgroups of youth who may have been particularly vulnerable to acute mental health problems during periods of social distancing and isolation. Proactive efforts to engage vulnerable youth in outpatient treatment during periods of increased infectivity may help prevent increasing symptoms from reaching the point of crisis.

Insurance and inpatient admission of emergency department patients with depression in the United States

OBJECTIVE

To estimate the contribution of insurance on rates of inpatient admission for emergency department visits with depression diagnoses.

METHODS

We identified 3,681,581 visits for depression in the National Emergency Department Sample (2007-2018). We classified them by concurrent injury, suicidal ideation, or neither. Payer categories were defined, non-exclusively, as Medicare, Medicaid, private insurance, and no insurance. Logistic regression models, adjusted for age, year, and comorbidities, were used to describe differences in rates of inpatient admission by payer type, stratified by visit features.

RESULTS

Rates of inpatient admission for visits with neither injury nor suicidal ideation (31.9%; 95%CI, 30.8-33.0) were lower than for visits with injury (37.9%; 95%CI, 36.7-39.1) or with suicidal ideation (39.7%; 95%CI, 37.3-42.1). Rates of admission were significantly lower for those without insurance (26.6%; 95%CI, 25.5-27.8) than for those with insurance (37.1%; 95%CI, 36.1-38.1). In adjusted models, insurance was associated with increased likelihood (OR = 1.81, 95%CI, 1.69-1.94) of admission. Insurance continued to be a significant predictor of admission among ED visits for depression with concurrent injury (OR = 1.39; 95%CI, 1.29-1.51).

CONCLUSION

After controlling for demographic characteristics and medical comorbidities, patients with depression who have insurance are significantly more likely to be admitted to the hospital compared to those without insurance.

Suicide and Self-Harm Outcomes Among Psychiatric Emergency Service Patients Diagnosed As Malingering

BACKGROUND

Malingering is a common and challenging clinical presentation in emergency departments (EDs).

OBJECTIVE

This study describes characteristics and outcomes among patients diagnosed as malingering in a psychiatric emergency service.

METHODS

Index psychiatric ED encounters were identified for all adult patients seen during a 27-month period. Mortality data were obtained for patients from the state public health authority, and repeat ED visits for self-harm were obtained from the state hospital association. Patients with a diagnosis of malingering were compared with those without a malingering diagnosis using correlative statistics and multivariable analyses.

RESULTS

Of 4710 encounters analyzed, 236 (5%) had a malingering diagnosis. No patients diagnosed as malingering died of suicide within 365 days of discharge, compared with 16 (0.4%) nonmalingering patients. Self-harm outcomes were available for 2689 encounters; 129 (5%) had a malingering diagnosis. Malingering was significantly associated with a repeat ED visit for self-harm within 365 days in multivariable analyses (adjusted odds ratio 2.52; 95% confidence interval 1.35-4.70); p < 0.01).

CONCLUSIONS

No psychiatric emergency service patients diagnosed as malingering died by suicide after discharge. New clinical approaches must balance malingering patients' apparent low suicide risk with their other substantial comorbidities and risk for self-harm.

Typology of psychiatric emergency services in the United Kingdom: a narrative literature review

BACKGROUND

Mental health crisis requiring emergency access to psychiatric service can occur at any time. Psychiatric Emergency Service (PES) is described as one that provides an immediate response to an individual in crisis within the first 24 h. Presently, several types of PESs are available in the United Kingdom (UK) with the aim of providing prompt and effective assessment and management of patients. Therefore, this study aims to provide a detailed narrative literature review of the various types of Psychiatric Emergency Service (PES) currently available in the UK.

METHOD

Electronic search of five key databases (MEDLINE, PsychINFO, EMBASE, AMED and PUBMED) was conducted. Studies were included if it described a mental health service in the UK that provides immediate response in mental health crisis within the first 24 h. Excluded studies did not describe a PES, non-English, and were not conducted in UK.

RESULTS

Nine types of PESs were found. Amongst the 9 services, more papers described crisis resolution home treatment. Majority of the papers reported services within England than other countries within the UK.

CONCLUSION

All types of PESs were described as beneficial, particularly to mental health service users, but not without some shortcomings. There is a need to continue carrying out methodological research that evaluate impact, cost-effectiveness as well as identify methods of optimising the beneficial outcomes of the various types of PESs. This may help inform researchers, policy makers and commissioners, service users and carers, service providers and many more on how to ensure current and future PESs meet the needs as well as aid recovery during crisis.

Psychiatric Emergency Services - Can Duty-Hour Changes Help Residents and Patients?

Limitations on resident duty hours have been widely introduced with the intention of decreasing resident fatigue and improving patient outcomes. While there is evidence of improvement in resident well-being and education following such initiatives, they have inadvertently resulted in increased number of hand-offs between clinicians leading to potential errors in patient care. Current literature emphasizes need for more specialty/setting-specific scheduling, while considering residents' opinions when implementing duty-hour reforms. There are no reports examining the impact of duty-hour changes on residents or patients in psychiatric emergency service (PES) settings. Our purpose was to assess the impact of a recent scheduling change and decrease in overall duty hours, on resident well-being and sense of burnout, while also evaluating changes to patient wait-time and length of stay (LOS) in PES. Residents completed Maslach Burnout Inventory and anonymous surveys focusing on: fatigue, sleep, life outside work for shifts - regular (8 am-8 pm) and swing shifts (12 pm-10 pm). Data from the electronic medical records were collected for 6 months pre- and post-schedule change (January 2016-February 2017), for LOS and patient wait-time. Residents' preference for shifts was split. However, 86% reported getting enough sleep during swing shifts, while 83% reported lack of sleep during regular shifts. The average patient wait-time and LOS significantly decreased from 169 to 147 and 690 to 515 min, respectively. The change to swing shifts significantly impacts LOS and patient wait-time. The short shifts demonstrated an improvement in well-being for residents, but were not the singular factor for overall resident satisfaction.

ED utilization of medical clearance testing for psychiatric admission: National Hospital Ambulatory Medical Care Survey analysis

INTRODUCTION

Routine medical clearance testing of emergency department (ED) patients with acute psychiatric illnesses in the absence of a medical indication has minimal proven utility. Little is known about the variations in clinical practice of ordering medical clearance tests.

METHODS

This study was an analysis of data from the annual United States National Hospital Ambulatory Medical Care Survey from 2010 to 2014. The study population was defined as ED visits by patients ≥18years old admitted to a psychiatric facility. We sought to determine the percentage of these ED visits in which at least one medical clearance test was ordered. Using a multivariate logistic regression model, we also evaluated whether patient visit factors or regional variation was associated with use of medical clearance tests.

RESULT

A medical clearance test was ordered in 80.4% of ED visits ending with a psychiatric admission. Multivariate logistic regression demonstrated a statistically significant increased odds ratio (OR) of medical clearance testing based on age (OR 1.02, 95%CI 1.01, 1.03), among visits involving an injury or poisoning (OR 2.38, 95%CI 1.54, 3.68), and in the Midwest region as compared to the Northeast region (OR 2.2, 95% confidence interval [CI] 1.09, 4.46), after adjusting for other predictors.

DISCUSSION

Our study demonstrated that, on a national level, 4 out of 5 ED visits resulting in a psychiatric facility admission had a medical clearance test ordered. Future research is needed to investigate the reasons underlying the discrepancies in ordering patterns across the U.S., including the effect of local psychiatric admission policies.

Highlight in Telepsychiatry and Behavioral Health Emergencies

Carolinas HealthCare System is one of the largest freestanding psychiatric emergency departments in the country. It has grown from a small community mental health center in the 1930s, to one of the largest providers of emergency mental health services in the country. It offers services in person and via telepsychiatry to other emergency departments and primary care clinics. It decreased emergency room wait times and revolutionized where and how patients get their care. This has been the work of several groups from many disciplines. The transition from community mental health center to large-scale mental health emergency department has been a model for the rest of the country.

[Work satisfaction and exhaustion among psychiatrists in psychiatric emergency services]

BACKGROUND AND AIM

Psychiatric emergency services (PES) have recently occupied a new and growing place in the landscape of mental health services. However, few data are available on the way psychiatrists practice in the PES. Our aim was to survey psychiatrists working in PES, focusing on their job satisfaction and the theoretical models they use in their everyday practice.

METHOD

We sent a survey to a sample of 508 psychiatrists working in PES in France.

RESULTS

Two hundred and thirty-seven psychiatrists returned the survey, yielding a response rate of 47%. On a 0 to 10 scale, the mean level of job satisfaction was 6.7 (SD: 1.92). Participants reported that facing a variety of clinical situations and playing a key-coordinating role in the mental health system were the two most specific features of emergency psychiatry. The main sources of dissatisfaction were organizational issues and stressful clinical experiences, including violence or hostility. Sixty-three percent (n=150) of participants reported using more than two theoretical models in their practice, while the use of crisis models was reported by almost 40% of them. When assessed for suggestions to improve the PES, the majority of participants indicated that efforts should be focused on organizational factors.

CONCLUSION

While emergency psychiatry could appear as an ungrateful practice, the majority of psychiatrists who responded to our survey reported satisfaction with their work and highlighted its unique particularities. Future research and collaborations are needed to identify organizational models of PES and their better integration in mental health networks.

Developing a Community-Based Participatory Research Approach to Understanding of the Repeat Use of Psychiatric Emergency Services

Psychiatric emergency services (PES) remain a critical and under-examined component of the community mental health system. We describe how a unique community-academic partnership came together to examine repeat use of PES through the design and conduct of a qualitative study using a CBPR approach. The goals of the project were to: (1) develop a model of research which promoted the inclusion of people who use mental health services in the research process; and (2) design and conduct a study to examine the repeat use of PES through the inclusion of the perspectives and experiences of people who use these services.

Poly-traumatization and harmful behaviors in a sample of emergency department Psychiatric Intake Response Center youth

The purpose of this study is to examine risk factors for poly-traumatization, and the impact of poly-traumatization on harmful behaviors (suicidal, self-harm, and violent), among a group of pediatric patients presenting at an emergency department's psychiatric intake response center. We employed a retrospective medical chart review in a children's hospital for a 2-year span (N=260). The study employed 2 statistical analyses. The first analysis used multinomial logistic regression to model the odds of harmful behaviors comparing increasing numbers of co-occurring traumatization types. The second analysis employed latent class modeling techniques in three ways to (a) define different poly-traumatization populations, (b) examine the relationship between predictors and class assignment, and (c) examine the relationship between class assignment and harmful behavioral outcomes. About 62% of the sample presented with at least 1 traumatization type and about 50% one harmful behavior type. Compared to those with 1, 2, or 3 traumatization types, patients with 4 or more traumatization types have higher odds of harmful behaviors. The latent class analysis revealed 2 populations: High serious victimization and minimal traumatization. History of family mental health issues was the only significant predictor of class membership. Class membership was associated with all of the harmful behavioral outcome categories. These findings support consideration of poly-traumatization as a risk factor for the high occurrence of harmful behaviors in this sample of pediatric psychiatric patients and that history of family mental health issues may contribute to the high co-occurrence of poly-traumatization.

Usage of psychiatric emergency services by asylum seekers: Clinical implications based on a descriptive study in Denmark

BACKGROUND

Asylum seekers are found to be at high risk of mental health problems. Little is known about the use of acute psychiatric emergency services by asylum seekers.

AIM

To describe the usage of an inpatient/outpatient psychiatric emergency service in Denmark by adult asylum seekers, and discuss clinical implications.

METHOD

This descriptive study is based on retrospective data collected from patient charts during a 3-month period.

RESULTS

A total of 31 evaluations were made (3.3% of all evaluations), based on 23 asylum seekers. Patients originated from 16 different countries, were predominantly male and married. The group consisted primarily (61%) of failed asylum seekers. Most patients (81%) presented with relevant mental health problems. The main reasons for presenting to the acute psychiatric emergency service were suicidal ideation and/or behaviour (60%). The most frequent diagnosis given at the initial evaluation was ICD-10 F43.9 "reaction to severe stress, unspecified" (50%). Evaluations were made primarily by non-psychiatrists. No standardized screening or diagnostic instrument was used.

CONCLUSION

This first description of the use of an acute psychiatric emergency service by asylum seekers in Denmark shows some of the acute mental health needs asylum seekers present with. The findings of high levels of suicidal ideation and possible diagnostic difficulties are discussed, as well as possible improvements of the referral and psychiatric evaluation processes.

Acute psychiatric inpatient care: a cross-cultural comparison between two hospitals in Germany and Japan

BACKGROUND

Intercultural differences influence acute inpatient psychiatric care systems.

AIMS

To evaluate characteristics of acute inpatient care in a German and a Japanese hospital.

METHOD

Based on a sample of 465 admissions to the Psychiatric State Hospital Regensburg (BKR) and 91 admissions to the Hirakawa Hospital (HH) over a six-month period in 2008, data from the psychiatric basic documentation system (BADO) were analysed with regard to socio-demographic characteristics, treatment processes and outcome indicators.

RESULTS

Schizophrenia and related psychosis was the most common diagnosis in both hospitals. Cases at the BKR were admitted more quickly after onset of the present episode. Global Assessment of Psychosocial Functioning (GAF) ratings at admission were lower at the HH. Most admissions to both hospitals received psychopharmacological treatment, but more at the HH received psychotherapy. Length of stay was significantly longer at the HH (75 days) than at the BKR (28 days). Admissions to the HH were more improved with regard to GAF and clinical global impression (CGI).

CONCLUSIONS

Acute admissions in Germany provide intensive care with short hospitalization as crisis intervention. For acute admissions in Japan, comprehensive care for severe mental illness precedes emergency admissions and achieves greater improvement with longer hospitalization.

[Frequent visitors to psychiatric emergency service: Demographical and clinical analysis]

INTRODUCTION

Frequent visitors of psychiatric emergency wards are an important health care problem. Previous studies underlined that 2 % to 9 % of patients induce 15 % to 33 % of total clinical activity. Those patients have chronic and severe mental illness such as schizophrenia, associated with social and financial difficulties.

OBJECTIVE

The aim of this study was to describe demographic and clinical characteristics of frequent visitors to a psychiatric emergency ward in a French Academic hospital over 6years in comparison to non-frequent visitors.

METHODS

The study is based on a retrospective review of the psychiatric emergency wards' administrative and medical computer databases; data that included demographic, financial, clinical, and management information. During this 6-year study, the psychiatric ward recorded 16,754 care episodes for 8800 different patients. We compared frequent visitors with other visitors using univariate and multivariate analyses. Frequent visitors were defined by a number of visits greater than 2 of the mean standard deviation.

RESULTS

Two percent of patients (n=192) had nine or more visits during the period. These patients caused 21 % of the total number of the visits. In the univariate analysis, the most significant reasons for referral in frequent visitors versus others (P<0.001) were: more frequent anxiety (37.6 % vs. 32.1 %), less frequent disruptive behavior (8.4 % vs. 12.9 %), depression (7.8 % vs. 17.2 %) and suicide attempt (4.5 % vs. 11.1 %). Factors associated with frequent visitors (P<0.001), after including all significant or confounding variables (multivariate analysis), were: schizophrenia and schizophrenia spectrum disorders (OR=29.5, IC: 11.4-76), DSM-IV cluster B personality disorders (OR=5.5, IC: 3.6-8.4), mental and behavioral disorders due to psychoactive substance use (OR=4.6, IC: 3.1-7), financial assistance through social government programs (OR range: 9.1-2.4, all significant) and being homeless (OR=2.7, IC: 1.8-4). Factors associated with non-frequent visitors were mood disorders (OR=0.07, IC: 0.03-0.19) and neurotic, stress-related, and somatoform disorders (OR=0.14, IC: 0.05-0.4). Sex and age were not significant in multivariate analysis.

DISCUSSION

This study identifies significant demographic and clinical factors associated with frequent visits in psychiatric emergency ward in accordance with the large majority of previous studies. We found that psychotic disorders or schizophrenia were the main diagnosis of these patients. Moreover, precariousness (homeless, financial assistance) is an important demographic factor associated with recurrence. However, contrary to numerous studies, we found no effect of sex or age. Due to this important economical and clinical burden, more specific care and alternative solutions to emergency care have to be proposed to this population of patients.

Do patients and clinicians differ in their assessment of suicidal intent after self-harm using the same suicide questionnaire scale?

There have been no studies looking at differences in clinicians and patients assessment of suicidal intent in adults after presenting to emergency departments with intentional self-harm. In a non-experimental correlational study patients were asked to complete the objective section of the Beck Suicide Intent Scale whilst clinicians, as part of their routine clinical evaluation, completed the same scale blind to the patients' ratings. Clinicians rated the suicide attempts consistently less seriously than the patients and there was poor agreement on individual questions (patients mean total score 6.86, clinicians mean total score 3.41, difference 3.45 (95% confidence interval 4.41-2.50) n=22, t=-7.52, p<0.01). The results may be explained by the requirement for clinicians to defend themselves against being overwhelmed by neediness, possibly leading to minimisation of the risk of suicide.