The use of a brief mental health screener to enhance the ability of police officers to identify persons with serious mental disorders

Police agencies in Canada and elsewhere have received much criticism over how they respond to persons with serious mental disorders. The adequacy of training provided to police officers on mental health issues and in particular on recognizing indicators of serious mental disorders has been a major concern. This paper describes the process that led to the development of a new brief mental health screener (interRAI Brief Mental Health Screener, BMHS) designed to assist police officers to better identify persons with serious mental disorders. The interRAI BMHS was developed in collaboration with interRAI, an international, not-for-profit consortium of researchers. The government of Ontario had previously partnered with interRAI to develop and implement the Resident Assessment Instrument for Mental Health (RAI-MH), the assessment system mandated for use on all persons admitted into inpatient psychiatric care in the province. Core items on the interRAI BMHS were obtained through analysis (N=41,019) of RAI-MH data together with input from representatives from health care, police services, and patient groups. Two police services in southwestern Ontario completed forms (N=235) on persons thought to have a mental disorder. Patient records were later accessed to determine patient disposition. The use of summary and inferential statistics revealed that the variables significantly associated with being taken to hospital by police included performing a self-injurious act in the past 30days, and others being concerned over the person's risk for self-injury. Variables significantly associated with being admitted included abnormal thought process, delusions, and hallucinations. The results of the study indicate that the 14-variable algorithm used to construct the interRAI BMHS is a good predictor of who was most likely to be taken to hospital by police officers and who was most likely to be admitted. The instrument is an effective means of capturing and standardizing police officer observations enabling them to provide more and better quality information to emergency department (ED) staff. Teaching police officers to use the form constitutes enhanced training on major indicators of serious mental disorders. Further, given that items on the interRAI BMHS are written in the language of the health system, language acts as common currency between police officers and ED staff laying the foundation for a more collaborative approach between the systems.

Psychiatric Boarding in Washington State and the Inadequacy of Mental Health Resources

Psychiatric boarding is a term derived from emergency medicine that describes the holding of patients deemed in need of hospitalization in emergency departments for extended periods because psychiatric beds are not available. Such boarding has occurred for many years in the shadows of mental health care as both inpatient beds and community services have decreased. This article focuses on a 2014 Washington State Supreme Court decision that examined the interpretation of certain sections of the Washington state civil commitment statute that had been used to justify the extended boarding of detained psychiatric patients in general hospital emergency departments. The impact of this decision on the state of Washington should be significant and could spark a national debate about the negative impacts of psychiatric boarding on patients and on the nation's general hospital emergency services.

[The imminent peril in the law of July the fifth 2011, two years later: the impact on health?]

In 1938, the French government decided to enact a first legislation to enforce admission of the mentally ill to hospitals. Later in 1990, the law took into consideration the evolution of practices with an increase of free admissions and the right to maintain the mentally ill in cities. Three types of psychiatric hospitalization were defined: free, on third party request and for involuntary confinement. A review had theoretically to be conducted every 5 years. In practice this was not the case, probably due to the balance between individual freedom, patient care and public safety always hard to find. However, considering the imperative European harmonization and the fact the Constitutional Council declared a double unconstitutionality of the law, the Act of July 5th was enacted in a hurry during the summer 2011. The Act defines the "rights and the protection of people subject to psychiatric care and methods of coverage". In this document, we will briefly review the context of this law. We will also explore the clinical implications of the very innovative measure: the "péril imminent". We will use the admissions at the Sainte-Anne hospital in Paris in 2010 to 2012. Three major key points were introduced in the law: a judge controls an agreeable release after 15 days and 6 months of continuous hospitalization. The law let the new possibility to provide ambulatory cares under constraints, and these to make an involuntary confinement without a third party request, using the "imminent peril". This law implies the involvement of the judge and the lawyer. This one has to defend a client who needs care, he controls the formal validity of decisions concerning the patient. To provide treatment without consent in "imminent peril" to someone, conditions are requested: these mental disorders make his consent impossible and his mental state requires immediate care with immediate care of constant medical monitoring justifying a full hospitalization or regular medical monitoring for support under another form of full hospitalization (Article L.3212. 1 of the Code of Public Health). Moreover, a demand for care by a third party has also to be impossible to obtain and an imminent peril to the person's health has to exist, supported by a medical certificate from a doctor who does not belong to the patient's psychiatric hospital. The imminent peril would be an immediate danger to the health or life of the patient. What has been the impact of this law adopted in emergency at Sainte-Anne hospital? This psychiatric hospital is in charge of the population in southern Paris, where reside about 655,000 people. This work observes the evolution of the type of hospitalization and care before and after the adoption of the law. We can observe an overall increase in entries under constraints. There is a decrease in admissions for involuntary confinement for the benefit of imminent peril. This imminent peril corresponds to only a small proportion of hospitalizations without consent but are rising between 2011 and 2012, perhaps in part due to a better understanding of the law. But this progression is to monitor to ensure compliance with the restrictive conditions laid down by this law. Also note that the imminent peril may be used at the refusal of the family or entourage to make the demand for care. The number of hospitalizations at the request of a third party with two certificates is down, which is probably due to a change in status of the CPOA, emergency structure within Sainte-Anne, which is no longer seen as extraterritorial. The imminent peril has advantages: it allows access to the care of people isolated and desocialized, of people whose identity is unknown, of pathological travellers. It avoids hospitalization at the request of the representative of the State for social reasons and not for risks to the safety of persons, even when this type of hospitalization is more stigmatizing and often more difficult to remove. It protects the entourage sometimes, when the family is ambivalent or hostile to care, or has been designated as a persecutor. The imminent peril also has disadvantages. One of them is the risk of its misuse to allow rapid hospitalization without taking the time to seek a third party. The imminent danger made when there is an entourage but which refuses to request care can undermine the development work on information about the disease, the need for care and treatment and the importance of the involvement of the entourage in the care plan. The alliance with the patient may be compromised. In some cases, a decision of care by the request of the representative of the State is more appropriate than the "imminent peril". The "imminent peril" may be preferred because of the administrative burden of prefectural measures when patient presents clinical improvement and we would go up to the ambulatory care in a care program. Yet, the use of a symbolic third, carrying authority, can avoid the too direct confrontation with the patient. Do not use it can complicate the management of the patient. Finally, with desocialized patients, imminent peril can facilitate access to care, but not continuity of care. Indeed, for the care program it is necessary to have an address for the patient. Once the crisis is not to develop a plan of care. Finally in some situations of desocialized patients, the imminent peril can promote access to care but not the continuity of care as to the care program it is necessary to have an address for the patient. Once the crisis is past, it is impossible to implement a program of care. The Law of 5 July 2011 marks a change in the practice of psychiatrists. Take into account the fundamental rights of the patient and to harmonize legislation at EU level was necessary. Some measures are designed to promote access to care as the "imminent peril", we now need to be vigilant to ensure that it is not diverted to promote an increase in care under constraints and that psychiatrists remain in an obligation of means and not of result.

The outcome of mental health care users admitted under Section 40 of the South African Mental Health Care Act (No 17 of 2002)

OBJECTIVE

To determine the outcomes of mental health care users (MHCU's) admitted in terms of Section 40 of the South African Mental Health Care Act (No 17 of 2002) (MHCA) and the factors, if any, that are associated with these outcomes.

METHOD

The study was a retrospective record review of MHCU's, 18 years and older, referred by the South African Police Service (SAPS) to Chris Hani Baragwanath Hospital (CHBH). All mental health care users handed over to CHBH by SAPS with completed MHCA form 22's during the period July 2007 to December 2007 were included in the study. The outcomes, demographics and clinical characteristics of these referrals were obtained from hospital records.

RESULTS

During the six-month study period, 718 MHCU's were referred by members of SAPS to the CHBH Emergency Department. Associations were found between discharged MHCU's and i) being male, ii) being less than 35 years of age, iii) being unemployed, iv) having a lower level of education, v) having a past history of substance abuse and/or vi) a past psychiatric illness. Females were twice as likely to be unemployed and admitted to hospital (either to a psychiatric or general medical ward). MHCU's diagnosed with delirium were more likely to be admitted into a medical ward as compared to a psychiatric ward.

CONCLUSION

As has been the case in most countries where police services have been incorporated into mental health acts, South Africa's new Mental Health Care Act (No 17 of 2002) has resulted in a large number of referrals by the police to mental health services. However, many of these referrals may not be necessary as most MHCU's end up not being admitted. The characteristics of police referrals suggest that the receiving facility should have the capacity to identify factors that favour outpatient care (especially substance abuse problems) and divert MHCU's presenting with such factors to appropriate treatment facilities without admitting them to the hospital.

[Admission and treatment without consent in Spain]

The notions of voluntary and involuntary admission are specific to the hospitalisation methods in Spain. In this context, the court is present at every stage of hospitalisation. Likewise, involuntary outpatient treatment, which has existed for several years, is a source of controversy and debate between the imposition of treatment and the therapeutic alliance.

[A reaffirmed French psychiatric public sector]

Psychiatry in France is considered here with regard to patient care systems, long-term treatments, treatment without consent and the place of the users in the system. The implementation of the new law in 2011 relating to admission to hospital without consent will have to be revised as a result of the problems identified during its application.

[Is it really possible to be treated without consent? ]

The law of July 5th, 2011 focuses on two distinct areas: the security aspect and that of the protection of people through the intervention of the liberties and detention judge. The care programme thus resembles house arrest, despoiling the sincerity of the trust-based relationship sought by caregivers. The systematic appearance of patients hospitalised under restraint before the liberty and detention judge risks creating confusion between care and delinquency. This article gives the viewpoint of the "39 contre la nuit securitaire" collective.

[The objectives of the reform of hospitalisation under restraint in psychiatry]

The law of July 5th, 2011 reforms legislation dating from June 27th, 1990. It adds elements identified as missing from the original text over the course of the years following its application. The systematic intervention of a liberties and detention judge could counterbalance the measures simplifying hospitalisation under restraint. Stricter monitoring of "unwieldy" patients is also included in measures which enable treatment under restraint to be given through outpatient care.

Covert medication in psychiatric emergencies: is it ever ethically permissible?

Covert administration of medications to patients, defined as the administration of medication to patients without their knowledge, is a practice surrounded by clinical, legal, ethics-related, and cultural controversy. Many psychiatrists would be likely to advocate that the practice of covert medication in emergency psychiatry is not clinically, ethically, or legally acceptable. This article explores whether there may be exceptions to this stance that would be ethical. We first review the standard of emergency psychiatric care. Although we could identify no published empirical studies of covert administration of medicine in emergency departments, we review the prevalence of this practice in other clinical settings. While the courts have not ruled with respect to covert medication, we discuss the evolving legal landscape of informed consent, competency, and the right to refuse treatment. We discuss dilemmas regarding the ethics involved in this practice, including the tensions among autonomy, beneficence, and duty to protect. We explore how differences between cultures regarding the value placed on individual versus family autonomy may affect perspectives with regard to this practice. We investigate how consumers view this practice and their treatment preferences during a psychiatric emergency. Finally, we discuss psychiatric advance directives and explore how these contracts may affect the debate over the practice.

"Personality disorder" and capacity to make treatment decisions

Whether treatment decision-making capacity can be meaningfully applied to patients with a diagnosis of "personality disorder" is examined. Patients presenting to a psychiatric emergency clinic with threats of self-harm are considered, two having been assessed and reviewed in detail. It was found that capacity can be meaningfully assessed in such patients, although the process is more complex than in patients with diagnoses of a more conventional kind. The process of assessing capacity in such patients is very time-consuming and may become, in itself, a therapeutic intervention.

Medical response time to section 5(4) (nurses' holding power) of the Mental Health Act 1983 over a 24-year period

This study examines the trends associated with medical response time (MRT) for all section 5(4)s of the Mental Health Act 1983 applied in one mental health trust over a 24-year period. Eight hundred and three section 5(4)s were applied during the study period of which 786 had a recorded medical response time. The mean MRT was 140 minutes and 647 (82.3%) patients were seen by a doctor within the four-hour period specified in the Mental Health Act Code of Practice (DoH, 1999). Analysis of MRT showed no significant difference with the day of the week or when the weekday mean MRT was compared to that for the weekend. A significant difference was observed for the mean MRT prior to, and following, the introduction of the four-hour period noted in the MHA Code of Practice. Significant differences were also observed for the MRT over the 24-hour period . The mean MRT for the 'working hours' period was significantly higher than that for the combined period Monday-Friday, 5pm-9am, and Saturday and Sunday. The findings suggest the need for mental health trusts to review their practices to ensure that patients receive a medical assessment in the shortest period of time following the application of section 5(4).

Dilemmas related to compulsory admission: a case report

The paper presents legal and practical dilemmas concerning compulsory admission by means of a case report.

Effects on outpatient and emergency mental health care of strict Medicaid early periodic screening, diagnosis, and treatment enforcement

We investigated enforcement of mental health benefits provided by California Medicaid's Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program. Enforcement, compelled by a consumer-driven lawsuit, resulted in an almost 4-fold funding increase over a 5-year period. We evaluated the impact of enforcement on outpatient treatment intensity (number of visits per child) and rates of emergency care treatment. Using fixed-effects regression, we examined the number of outpatient mental health visits per client and the percentage of all clients using crisis care across 53 autonomous California county mental health plans over 32 three-month periods (quarters; emergency crisis care rates) and 36 quarters (out-patient mental health visits). Enforcement of EPSDT benefits in accordance with federal law produced favorable changes in patterns of mental health service use, consistent with policy aims.

Is there a duty for private employers to provide emergency mental health care services?

This article presents a discussion of whether employers in private companies have a duty to provide an emergency action plan with a mental health component for its employees. It discusses basic negligence concepts and focuses mainly on the "duty of care" component of negligence. It then applies the negligence concepts to private employers and discusses how private companies arguably might have a duty under the laws of negligence to provide employees with an emergency action plan, specifically a plan including mental health provisions.

Emergency management of agitation in schizophrenia

Schizophrenia is a common psychiatric condition, affecting approximately 1% of the population. Acute emergent presentations often include hallucinations, delusions, thought, and speech disorders. Agitation is common among emergency patients with schizophrenia. Decisional capacity should be assessed in all patients. Reversible causes of agitation should be ruled out, including infection, metabolic disorders, endocrine disorders, trauma, pain, noncompliance, toxicological disorders, and structural brain abnormalities. Agitation may be managed acutely using a combination of pharmacological agents and nonpharmacological interventions. Effective pharmacological agents include several classes of antipsychotic agents and benzodiazepines. Potential life-threatening complications of pharmacological therapy should be anticipated, which may include neuroleptic malignant syndrome (NMS), prolonged QT syndrome, and respiratory depression. Nonpharmacological interventions may include a quiet environment, physical restraints, and behavioral interventions. Disposition decisions should be made based on the etiology of agitation, effective management, decisional capacity, and presence of suicidal or homicidal intentions. Many patients who have required nonpharmacological or pharmacological management of agitation require inpatient psychiatric treatment, either voluntarily or involuntarily. Psychiatric consultation should be sought for patients with schizophrenia and uncertain disposition determinations, or those requiring other complex management decisions.

Preplanning can ease psychiatric transfers

ED managers should know what potential accepting facilities are available in the community for psychiatric patients and what their transfer policies are. Find out the local facilities to which you may be transferring patients and the resources they have available. "Way stations," small psychiatric holding centers, may be a viable option in your community. Come to a mutual understanding on the Emergency Medical Treatment and Labor Act and transfers with potentially accepting facilities.

Contrasting jail diversion and in-jail services for mental illness and substance abuse: do they serve the same clients?

Baseline data from a study of jail diversion services and in-jail behavioral health services were used to examine the differences in clients served by these two models of responding to people with co-occurring mental health and substance abuse problems in the criminal justice system. Clients of the diversion service had more acute psychiatric symptoms and were more likely to have a diagnosis of psychosis NOS. Clients of the in-jail service were more likely to have been on probation or parole in the past and to have received substance abuse treatment. Different service models may attract and serve different populations of clients. Diversion services may cast a wider net that includes clients who may not have otherwise been involved in forensic services.

Duty of care in the emergency department

This paper explores issues that relate to the management of deliberate self-harm in the emergency department (ED) from a New South Wales perspective. A scenario that is typical to the ED is presented to illustrate the dilemma that nurses face and the implications for clinical practice. Confusion and concern regarding the treatment and detention of this type of patient in the ED can often result in the inappropriate use of the Mental Health Act. It is preferable for clinicians to be aware of the treatment options they have under duty of care rather than relying on the unfounded reassurance provided by scheduling a patient under the Mental Health Act. Communication and negotiation skills are highlighted as attributes that clinicians must develop and enhance to effectively manage difficult presentations to the ED.

Comparing aspects of mental health legislation of Israel and Massachusetts

This paper compares the manner in which two sets of mental health laws, that of Massachusetts, U.S.A., and that of the State of Israel, deal with specific areas of civil enforced commitment. The definition of psychiatric disorder that justifies commitment is broader in Massachusetts, in Israel psychosis alone is considered, excluding conditions such as severe non-psychotic depression, obsessive-compulsive disorder and anorexia. In Israel, commitment is possible only when there is a risk of danger that is immediate. In Massachusetts, only a judge can make decisions beyond the first four days, while in Israel they are made by a District Psychiatrist. Unlike Massachusetts, there is no possibility of enforced commitment of alcoholics or drug addicts in Israel, even in the presence of impaired judgement and severe family distress. The changing trends are presented, as Israel seems to be drawing slowly toward the Massachusetts position in some of these issues. The role of consumers in these processes is considered, as is the possibility of enforced commitment of people with severe personality disorders.

Call 911: psychiatry and the new Emergency Medical Treatment and Active Labor Act (EMTALA) regulations

The Emergency Medical Treatment and Active Labor Act (EMTALA), enacted in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act of 1985, aims to prevent "patient dumping" by requiring hospitals to screen and stabilize patients who come to an emergency room seeking medical attention. For many reasons, recovery under EMTALA is rare, especially when psychiatric treatment is called for. New regulations of EMTALA went into effect on November 10, 2003. These new regulations helpfully clarify the applicability of EMTALA. However, the bias against recovery in cases involving psychiatric emergencies is likely to remain.

Legal considerations in the child psychiatric emergency department

Clinicians who practice in the child psychiatric emergency department have the complex task of evaluating the mental health or substance abuse needs of children, adolescents, and their families during times of crisis. Adding to this challenging clinical task are multiple legal considerations with which the clinician must be familiar. The precise impact of these legal issues varies from state to state. Some of these legal considerations are present at the start of the evaluation (consent for evaluation or treatment), during the evaluation (psychiatric hospitalization), and at the end of an evaluation (mandatory reporting of suspected child abuse and duty to warn or protect third parties from harm). Other issues (confidentiality and consent for release of information) are present at all stages of the evaluation and continue long after the evaluation has been completed. Clinicians who evaluate the psychiatric needs of children and adolescents are urged to review their local state laws relating to civil commitment, confidentiality, and mandatory reporting.

Implementing psychiatric advance directives: service provider issues and answers

Psychiatric advance directives (PADs) are an emerging method for adults with serious and persistent mental illness to document treatment preferences in advance of periods of incapacity. This article presents and responds to issues most frequently raised by service providers when planning for implementation of PADs. Issues discussed include access to PADs; competency to execute PADs; the relationship of PADs to standards of care, resource availability, and involuntary treatment; roles of service providers and others in execution of PADs; timeliness and redundancy of PAD information; consumer expectations of PADs; complexity of PADs; revocation and "activation"; legal enforceability of PADs; the role and powers of agents; liability for honoring and not honoring PADs; and use of PADs to consent for release of health care information. Recommendations are made for training staff and consumers, consideration of statute development, and methods to reduce logistical, attitudinal, and system barriers to effective use of PADs.

The Emergency Medical Treatment and Active Labor Act of 1985 and the practice of psychiatry

The landmark federal Emergency Medical Treatment and Active Labor Act of 1985 (EMTALA) requires that all patients who seek emergency treatment be given an adequate medical screening examination and prohibits discrimination on the basis of patients' ability to pay. Although the impact of EMTALA on psychiatric practice is clinically, ethically, and legally significant, many psychiatrists have had little formal training in the provisions of this legislation, and little discussion of it is found in the psychiatric literature. EMTALA will become increasingly important in a managed care environment with diminishing psychiatric resources and increasing demand to treat persons who are indigent or underinsured. Physicians familiar with EMTALA's provisions will be able to use the legislation to act in the best interests of their patients despite competing institutional and economic pressures. The authors present a brief history of EMTALA, followed by a summary of the major points of the legislation. They illustrate the "ten mandates of EMTALA" with clinical cases drawn from a typical psychiatric emergency service.

Mental health and substance abuse emergency response criteria. Final rule

Section 3102 of the Children's Health Act of 2000, Pub. L. 106-310, amends section 501 of the Public Health Service (PHS) Act (42 U.S.C. 290aa) to add a new subsection (m) entitled "Emergency Response." This newly enacted subsection 501(m) authorizes the Secretary to use up to, but no more than, 2.5% of all amounts appropriated under Title V of the PHS Act, other than those appropriated under Part C, in each fiscal year to make "noncompetitive grants, contracts or cooperative agreements to public entities to enable such entities to address emergency substance abuse or mental health needs in local communities." Because Congress believed the Secretary needed the ability to respond to emergencies, it exempted any grants, contracts, or cooperative agreements authorized under this section from the peer review process. See section 501(m)(1) of the PHS Act. Instead, the Secretary is to use an objective review process by establishing objective criteria to review applications for funds under this authority.

Psychiatric crises and emergency admissions

Emphasize safe practice to avoid legal liability when evaluating individuals in psychiatric crisis. Test your knowledge with the following questions, then check your answers at http://www.nursingmanagement.com.

Substance Abuse and Mental Health Services Administration; mental health and substance abuse emergency response criteria. Interim final rule

Section 3102 of the Children's Health Act of 2000, Pub. L. 106-310, amends section 501 of the Public Health Service (PHS) Act (42 U.S.C. 290 aa) to add a new subsection (m) entitled "Emergency Response." This newly enacted subsection 501(m) authorizes the Secretary to use up to, but no more than, 2.5% of all amounts appropriated under Title V of the PHS Act, other than those appropriated under Part C, in each fiscal year to make "noncompetitive grants, contracts or cooperative agreements to public entities to enable such entities to address emergency substance abuse or mental health needs in local communities." Because Congress believed the Secretary needed the ability to respond to emergencies, it exempted any grants,contracts, or cooperative agreements authorized under this section from the peer review process otherwise required by section 504 of the PHS Act. See section 501(m)(1) of the PHS Act. Instead, the Secretary is to use an objective review process by establishing objective criteria to review applications for funds under this authority. Pursuant to Public Law 106-310, the Secretary is required to establish, and publish in the Federal Register, criteria for determining when a mental health or substance abuse emergency exists. In this interim final rule, the Secretary sets out these criteria, as well as the intended approach for implementing this new mental health and substance abuse emergency response authority. The Secretary invites public comments on both the criteria and the approach described in this interim final rule.

Section 5(2) of the Mental Health Act 1983 in practice: an audit and a review

All applications of s.5(2) of the Mental Health Act 1983 (MHA) between January 1997 and December 1998 were examined to assess variables likely to affect outcome and to compare these findings to other similar published studies. Of the 154 applications (7% of all admissions), 56 were converted to s.3 and 39 to s.2 of the MHA. We found that the time of application, grade of doctor making the application and the day of application were the best predictors of outcome of s.5(2). Apart from a few exceptions, our findings were generally in keeping with previous published results. These findings suggest a national trend in the clinical use of s.5(2) and may provide a useful guide for those considering reform of this part of the MHA.

Detention of elderly psychiatric inpatients under section 5(2) of the Mental Health Act 1983

Emergency detention of elderly psychiatric inpatients appears to have attracted very little or no attention in published studies. In this retrospective review, all applications of sections 5(2) and 5(4) of the Mental Health Act 1983, detaining elderly inpatients in North Cheshire between 1985 and 1997 were reviewed. Forty-three percent of elderly inpatients under s.5(2) regained their voluntary status, while 57% were detained under another section by the end of the 72 hours (p < 0.05). Duration in hospital prior to applying s.5(2), clinical diagnosis of functional mental illness and use of s.5(4) appear to increase the likelihood of converting s.5(2) into other sections. The high rate of non-conversion of s.5(2) in the elderly to s.2 or 3 may imply that in almost half of the cases, emergency detention may have been used to control isolated incidents of disturbed behaviour in otherwise co-operative patients. Educating doctors and nurses in guidance put forward by the Code of Practice (1993) remains, probably, the main key to a better use of emergency holding powers.

Forensic issues in the psychiatric emergency department

To function effectively in the ED, mental health clinicians must be able to: Competently evaluate and manage psychiatric patients in acute crisis. Obtain informed consent for treatment or procedures from patients or substitute health care decision makers. Develop clinical data about patients from collateral sources, such as family members and current treaters. Retrieve records of previous admissions to the ED or hospital psychiatric unit. Conduct competent suicide and violence risk assessments that direct clinical interventions. Conduct risk-benefit assessments before discharging suicidal or potentially violent patients. Observe basic safety precautions and procedures with potentially violent patients. Work with community mental health facilities for the follow-up care of chronically mentally ill patients. Possess a working knowledge of the legal regulation of mental health practice, especially as it applies to evaluating and treating patients in the ED. Obtain legal consultation when in doubt about matters of law affecting patient care.

[The police in psychiatric daily routine]

PURPOSE

The following is a description of those patients brought by the police to the emergency room of a general hospital of Berlin for a psychiatric exploration.

METHOD

The medical records of those patients brought in to the emergency room during one year were analyzed retrospectively.

RESULTS

Within one year, 317 (10.8%) out of 2903 patients were brought by the police to have an emergency psychiatric exploration. The ratio of men to women was 2:1, and the median age was 41. Most illnesses diagnosed were schizophrenia, disorders caused by psychotropic substances, alcoholism, alcohol intoxication, and adjustment disorders/stress disorders. One third of the 317 patients were under influence of alcohol. 21.8% of the 317 patients were suicidal. Over two thirds of the patients were admitted to the psychiatric ward. Only 31 patients were not admitted to the ward for lack of indication. The most frequent reason for intervention of police was suicidal behaviour (35%), "strange behaviour" (28.7%) or aggressive behaviour (23%).

CONCLUSION

The results show that those patients brought in by the police are in acute crisis situations often involving suicidal tendencies and suffer from more severe psychiatric illnesses. The psychiatric emergency exploration initiated by the police was generally justifiable.