Contingency plan of the Clinical Management Unit for Psychiatry and Mental Health (CMUPMH) of the Infanta Cristina University Hospital (ICUH) for the COVID-19 pandemic

In recent decades, pandemics and health catastrophes have caused disorders in part of the population with quite diverse consequences (SARS in 2002-2003, Ebola in 2014- 2015) showing a tendency to create generalised fear in the population, stigmatisation of the sufferers and psychological effects in health-care staff themselves.

Suicide risk, personality disorder and hospital admission after assessment by psychiatric emergency services

BACKGROUND

The main objectives of the mobile Psychiatric Emergency Services (PES) in the Netherlands are to assess the presence of a mental disorder, to estimate risk to self or others, and to initiate continuity of care, including psychiatric hospital admission. The aim of this study was to assess the associations between the level of suicidality and risk of voluntary or involuntary admission in patients with and without a personality disorder who were presented to mobile PES.

METHODS

Observational data were obtained in three areas of the Netherlands from 2007 to 2016. In total, we included 71,707 contacts of patients aged 18 to 65 years. The outcome variable was voluntary or involuntary psychiatric admission. Suicide risk and personality disorder were assessed by PES-clinicians. Multivariable regression analysis was used to explore associations between suicide risk, personality disorder, and voluntary or involuntary admission.

RESULTS

Independently of the level of suicide risk, suicidal patients diagnosed with personality disorder were less likely to be admitted voluntarily than those without such a diagnosis (admission rate .37 versus .46 respectively). However, when the level of suicide risk was moderate or high, those with a personality disorder who were admitted involuntarily had the same probability of involuntary admission as those without such a disorder.

CONCLUSIONS

While the probability of voluntary admission was lower in those diagnosed with a personality disorder, independent of the level of suicidality, the probability of involuntary admission was only lower in those whose risk of suicide was low. Future longitudinal studies should investigate the associations between (involuntary) admission and course of suicidality in personality disorder.

Elevated allostatic load in individuals presenting at psychiatric emergency services

OBJECTIVE

Individuals requiring psychiatric emergency services are often highly distressed and intoxicated. To provide an objective and comprehensive measure of their stress-related physiological dysregulations, we indexed allostatic load with 14 biomarkers collected within 24 h of patients' admission to the largest psychiatric hospital in the Canadian province of Quebec.

METHODS

This study (N = 278) combines data for emergency patients (n = 76; 65.8% women; M age = 44.97, SE = 1.6) and hospital workers who served as sex- and age-matched controls (n = 202; 70.8% women; M age = 40.10, SE = 0.83). Sex-specific allostatic load indices summarized neuroendocrine (cortisol), immune (tumor necrosis factor-α, interleukin-6, c-reactive protein), metabolic (insulin, glycosylated hemoglobin, total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, body mass index), and cardiovascular (heart rate, systolic and diastolic blood pressure) functioning. Well-validated questionnaires assessed substance (ab)use.

RESULTS

Individuals presenting at psychiatric emergency showed elevated allostatic load, drug abuse, and tobacco use compared to controls. Elevated allostatic load in emergency patients was driven by elevated cortisol, interleukin-6, systolic blood pressure, and heart rate; however, allostatic load was not explained by substance (ab)use or demographic variables. Sub-group analyses revealed that emergency patients primarily diagnosed with bipolar, depressive, or anxiety disorders showed higher allostatic load than those diagnosed with personality disorder(s).

CONCLUSIONS

This study demonstrates that individuals presenting at psychiatric emergency services show physiological dysregulations associated with chronic stress. Future research should explore the clinical utility of allostatic load in predicting comorbidities among psychiatric patients.

Violence, research, and non-identity in the psychiatric clinic

Violence in psychiatric clinics has been a consistent problem since the birth of modern psychiatry. In this paper, I examine current efforts to understand and reduce both violence and coercive responses to violence in psychiatry, arguing that these efforts are destined to fall short. By and large, scholarship on psychiatric violence reduction has focused on identifying discrete factors that are statistically associated with violence, such as patient demographics and clinical qualities, in an effort to quantify risk and predict violent acts before they happen. Using the work of Horkheimer and Adorno, I characterize the theoretical orientation of such efforts as identity thinking. I then argue that these approaches lead to epistemic imperceptiveness and a subtle form of conceptual restraint on patients. I suggest a reorientation in psychiatric research, away from identity thinking and toward a more productive and just approach to the problem of violence in psychiatric clinics.

Home treatment in preventing hospital admission for moderate and severe mentally ill people

A Home Treatment team was compared with a Psychiatric Emergency Department (PED) on preventing hospitalization among two cohorts of 448 patients matched by diagnosis, sex, and age. The logistic regression showed that HT people were 4.6 times less likely to be admitted than those from PED.

Emergency compulsory admissions in the Netherlands: fluctuating patterns in Rotterdam, 1929-2005

This paper identifies the social changes and developments in public mental health that have contributed to fluctuations in the use of emergency compulsory admissions in Rotterdam, the Netherlands. Annual reports and administrative data over the years 1929-2005 indicate the impact of general and local factors. Demographic changes and statutory regulations were important general factors, but do not explain particular swings in the number of compulsory admissions. Key local factors were: the availability of alternative arrangements such as emergency centres and sheltered homes; an interpretation of the criteria for compulsory admissions shared by all disciplines involved; and better collaboration between services. These factors suggest that if the increasing use of compulsory admissions is to be reversed, a coordinated effort is needed.

[Changes in crisis intervention and emergency psychiatry, Amsterdam emergency consultations in 1983 and 2005]

BACKGROUND

Since 1992 The Netherlands has seen a striking increase in the number of compulsory admissions. There is a danger that coercion will become the dominant form of treatment in the Amsterdam clinics.

AIM

To build up a picture of the changes in emergency psychiatry which have contributed to the increase in the number of acute compulsory admissions.

METHOD

A cohort (n = 460) of consultations conducted by the city crisis service in 1983 was compared with a similar cohort (n = 436) of consultations conducted in 2004-2005 based on the following variables: crisis-service procedures, patient characteristics, diagnosis and consultation outcomes.

RESULTS

In 2003-2004 more services were involved with psychiatric patients in acute situations in the public domain than were involved in 1983. The number of patients referred by the police almost doubled, rising from 29.3 to 62.7%. In 1983 all consultations took place where the patients were located; in 2004-2005 60% took place at the premises of the crisis service. The number of psychotic patients in the cohort rose from 52 to 63.3%. There was a rise in the number of compulsory admissions (from 16.7 to 20%) and a sharp decline in voluntary admissions (from 25.7 to 7.6%). The total number of admissions following a consultation decreased from 42 to 28%.

CONCLUSIONS

The front-line outreach service of 1983 has been transformed into a specialist psychiatric emergency department with only a modest outreach component. Voluntary admissions via the consultation service have almost ceased. Further research is needed into the characteristics of the consultations and into the variables that play a role in the use of compulsion in emergency psychiatry.

A statewide Crisis Intervention Team (CIT) initiative: evolution of the Georgia CIT program

In late 2004, Georgia began implementation of a statewide Crisis Intervention Team (CIT) program to train a portion of its law enforcement officers to respond safely and effectively to individuals with mental illnesses who are in crisis. This overview provides a description of the evolution of the Georgia CIT, including discussions of the historical context in which the program developed; the program's vision, mission, and objectives; the importance of the multidisciplinary Georgia CIT Advisory Board; the training curriculum; the role played by state and local coordinators; the value of stakeholders' meetings; practical operations of the program; the importance of considering the adequacy of community-based and hospital-based psychiatric services; costs and funding; the program's expansion plan; and evaluation, research, and academic collaborations. These detailed descriptions of the Georgia CIT program may be useful for professionals involved in local, regional, or state CIT program planning and may provide a practical synopsis of one example of this collaborative model that is being rapidly disseminated across the U.S.

[Emergency psychiatry in Belgium; a challenge for the mental health services]

In Belgium emergency psychiatry is a discipline that has developed only recently, following two federal pilot projects, one in 1993 and one in 2002. At present there are 10 subsidised psychiatric emergency rooms (pers) in Belgium, serving about 13,000 patients annually. Many of those seeking help are 'revolving-door' patients, but the pers also serve patients who have had no prior contact with the mental health care service. The disorders that are encountered most often have to do with substance abuse (about 30%) and mood disorders (17%). More than 4 in 10 patients were admitted to a psychiatric clinic after being referred to a per. Research suggests that the link to continuous care may reduce the 'revolving-door' phenomenon.

[Emergency psychiatry in Amsterdam: a historical case study]

Over the past 25 years the system of centralised management of emergency psychiatry has disappeared and re-appeared. Since 2000 improvements have been made in the logistics, organisation and quality of emergency care. In the same period, however, there has been a horrendous increase in the number of compulsory admissions in the main Dutch cities. The authors hypothesise that this increase may be due partly to organisational changes in the psychiatric emergency services and partly to the introduction of a new mental health act and changes in society.

Shrinking inpatient psychiatric capacity: cause for celebration or concern?

This issue brief examines reported capacity constraints in inpatient psychiatric services and describes how these services fit within the continuum of care for mental health treatment. The paper summarizes the type and range of acute care services used to intervene in mental health crises, including both traditional hospital-based services and alternative crisis interventions, such as mobile response teams. It reviews historical trends in the supply of inpatient psychiatric beds and explores the anticipated influence of prospective payment for inpatient psychiatric services under Medicare. The paper also considers other forces that may affect the need for and supply of acute mental health services, including key factors that could improve the quality and efficiency of inpatient psychiatric care.

Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001

OBJECTIVE

The objective of this study was to ascertain trends in mental health-related visits to U.S. emergency departments.

METHODS

Data were obtained from the National Hospital Ambulatory Medical Care Survey by using mental health-related ICD-9-CM, E, and V codes as well as mental health-related reasons for visit.

RESULTS

From 1992 to 2001, there were 53 million mental health-related visits, representing an increase from 4.9 percent to 6.3 percent of all emergency department visits and an increase from 17.1 to 23.6 visits per 1,000 U.S. population across the decade. The most prevalent diagnoses were substance-related disorders (22 percent of visits), mood disorders (17 percent), and anxiety disorders (16 percent). Mental health-related visits increased significantly among non-Hispanic whites, patients older than 70 years, and patients with insurance. Medications were administered during 61 percent of all mental health-related visits, most commonly psychotropic medication, the prescription rate of which increased from 22 percent to 31 percent of visits over the decade. Ten-year increases in mental health-related emergency department visits were significant for all U.S. geographic regions except the Midwest.

CONCLUSIONS

Mental health-related visits constitute a significant and increasing burden of care in U.S. emergency departments.

Trends and shifting ecologies: Part I

Ultimately, decreased hospital lengths of stay, endemic shortages of psychiatric hospital beds, lengthy waits for indicated outpatient services, and closing of residential treatment facilities, safe homes, and detention centers have led to what could be viewed as a children's mental health service "de-institutionalization." Only critical shifts in the underlying philosophy, practice, financing, and perceived role of hospital-based child and adolescent psychiatric emergency service will put the pediatric emergency department in a position to keep up with the accelerating service demands.

Trends and shifting ecologies: Part II

Community-based systems of care offer some promising ecologically based approaches to child psychiatric emergencies. More community-based effectiveness research is needed on child and adolescent mental health crisis services. To meet the needs of real-world children with serious emotional disorders and their families, however, research should include integration of multiple evidence-based modalities (such as psychopharmacology, behavioral, and cognitive approaches) and the effectiveness of single modalities. Funding priorities in mental health systems also should shift significantly to support community-based crisis services over more restrictive approaches that have a less solid evidence base.

Psychiatric emergencies and the millennium: an international study

BACKGROUND

The millennium posed an unknown challenge to mental health services worldwide. In anticipation, contingencies were implemented in preparation for the unexpected impact on psychiatric morbidity.

RESULTS

This study evaluates the impact of the millennium on psychiatric emergency service utilization in the Northern and Southern hemispheres--the UK, Nigeria and Australia. Findings did not demonstrate a notable "millennium effect" on mental health services. A number of patients presented psychopathology incorporating millennium themes. A post-Christmas and post-New Year increase in presentation was observed.

CONCLUSION

There was no change in service needs.

Emergency child mental health services in Poland

This paper describes emergency child mental health services in Poland. The paper defines common emergencies for children and adolescents, describes who responds and how services are organized. The evaluation process, interventions and treatment follow-up are outlined. The lack of consistency across Poland is highlighted. Recommendations for further training of professionals, as well as improvements in the mental health and legal systems are made.

Child and adolescent mental health emergency services in Eastern European former Iron Curtain countries

This paper describes the evolution of child and adolescent mental health emergency services in Eastern European countries over the past decade since the dissolution of the Iron Curtain. The process of helping countries to organize services, as facilitated by the authors through their training and mentoring of Eastern European mental health professionals, organized by the Children's Mental Health Alliance Foundation, with funding from the Soros Foundation, is described. This paper is a prelude to reports from six Eastern European countries which describe in more detail how child and adolescent mental health emergencies are evaluated and treated locally.

Child and adolescent mental health emergency services in Macedonia

This paper describes the development of child and adolescent mental health emergency services in Macedonia since 1993. The evolution of services through the Mental Crisis Centre for Children and Adolescents, funded by the Open Society Institute, and located in six cities is outlined. The paper also defines traditional services, the nature of child mental health emergencies, the evaluation process, follow-up care and training and supervision. It concludes with concern that the mental health emergency system is not sufficient to meet the needs of the child and adolescent population, particularly in the face of the Kosovar refugee crisis. Recommendations for the future are made.

Child and adolescent mental health emergency services in Lithuania

This paper describes the development of emergency mental health services for children and adolescents in Lithuania over the past decade. The dramatic changes in child and adolescent psychiatry which correspond to the move away from the Soviet school to democracy and the restoration of the independent Lithuanian state are outlined. The paper includes: the nature of child mental health emergencies in Lithuania, how they are evaluated, follow-up care, training and supervision, and societal emergencies. Recommendations for the future are made.

Emergency child mental health services in Estonia

This paper describes emergency child mental health services in Estonia. The paper defines what is an emergency in Estonia, who provides services to children and adolescents, the process of evaluation, follow-up care and societal emergencies. Centers for care in Tartu and Tallin are described. The need for ongoing training and the expansion of services into the countryside is noted.

Emergency services in Czech Republic

This paper describes emergency mental health services for children and adolescents in the Czech Republic. The paper defines need for emergency services, describes who provides care, where and how it is provided and follow-up care. Training of professionals and societal emergencies are also noted. While a range of services exists, increased specialty training for mental health professionals is recommended.

Emergency child mental health services in Latvia

This paper describes emergency child mental health services in Latvia. The paper defines child mental health emergency and outlines which professionals are involved in evaluation and where evaluations occur. The described follow-up services are only now developing, with the majority of children still receiving minimal mental health services in shelters or detention centers. Recommendations for more training of professionals, specific protocols and an integrated system of care are made.

A second survey of Scottish emergency psychiatry

OBJECTIVE

To survey NHS services providing emergency psychiatric assessment in Scotland and to compare the findings with those of the survey conducted 8 years ago.

DESIGN

Postal and telephone questionnaire of all primary care trusts, the one integrated trust and three Island Health Boards in Scotland.

RESULTS

All parts of Scotland provide a 24 hour service for the assessment of psychiatric emergencies. There is a range of multidisciplinary responses during office hours with a total of 75 multidisciplinary Community Mental Health Teams, 18 Community Psychiatric Nursing Teams, 11 liaison psychiatry teams and one dedicated emergency team. However, for most of the week, the service is provided by a duty basic grade doctor in each area with the exception of Orkney.

CONCLUSIONS

Planning the most appropriate emergency and crisis service for any population depends on suitable data being available. Eight years after the first survey there is still no systematic collection of data on emergency contacts in Scotland. The systematic collection of National data is required for effective audit, planning and development of these services. The working definitions proposed in the first survey would be suitable for coding.

[Community-integrated acute psychiatric care. Options and limitations]

The shift of psychiatric care from the hospital to the community has been accompanied by a reduction of hospital beds and shortened durations of inpatient treatment, but also by an increase in admissions. This evolution may be largely attributed to the prime focus of community mental health institutions on rehabilitation. The continued implementation of reforms in psychiatric care is contingent upon effectively halting the "revolving door phenomenon" by incorporating community-integrated treatment approaches into the care of acutely ill patients. Since the mid-1960s, a series of studies have established the efficacy of two community-integrated modalities for the treatment of acute psychiatric illness, i.e. home-based and day hospital treatment. In general, these approaches not only seem to be as effective as inpatient care for certain groups of patients but also reduce their need of hospitalisation, thereby contributing towards a cost effective, comprehensive psychiatric care system.

Rehab rounds: overcoming barriers to individualized psychosocial rehabilitation in an acute treatment unit of a state hospital

Psychiatric rehabilitation begins during the acute stages of a psychiatric disorder and continues throughout the person's lifetime, with the types of services flexibly keyed to the person's phase of illness, needs, and personal goals. During periods of relapse and exacerbation of symptoms, when hospitalization is often required, psychiatric rehabilitation should include the following five objectives: * Clarify how the person's own goals in life, such as a desire for more self-control, freedom of choice, privacy, and time with friends and family, can be served by inpatient treatment and symptom stabilization. * Educate the patient about the nature of his or her illness and how medications work to restore self-control. * Teach the patient about side effects and self-monitoring and negotiating about medication and its effects in a collaborative way with the psychiatrist and other members of the treatment team. * Connect with the family or other natural supports that the person has in the community. * Enable the patient to make appropriate aftercare plans for residential and continuing treatment needs after discharge. When rehabilitation is viewed from the vantage point of these objectives, the inextricable interweaving of "treatment" with "rehabilitation" becomes clear. Treatment and rehabilitation are two sides of the same. It is much easier to integrate psychiatric rehabilitation into more traditional methods of treatment than it is to reorganize a treatment program or facility so that it blends rehabilitation with prevailing treatment imperatives of pharmacotherapy, supervision, and security and safety. In previous Rehab Rounds columns, we have described examples of creative methods for bringing the principles and practices of psychiatric rehabilitation into the treatment milieu (1,2,3). Faced with regulatory criticism from governmental agencies, Dr. Dhillon and his colleagues at Eastern State Hospital in Williamsburg, Virginia, launched a vigorous initiative to bring psychiatric rehabilitation into the forefront of their clinical enterprise. To enable readers to learn from their successful experience and adapt some of the administrative and clinical procedures that worked in Virginia, Dr. Dhillon and Ms. Dollieslager describe the operational details of their odyssey. We believe that their effectiveness in changing a traditional institution can be duplicated in many other places-in units within general hospitals or other community-based settings-as well as in state psychiatric hospitals, where acute treatment has been limited to pharmacotherapy and recreational and diversional activities.

The psychiatric emergency service: where we've been and where we're going

The Psychiatric Emergency Service (PES) has evolved into a separate service with its own space and staff specialized for the handling of psychiatric emergencies. A study of trends in our PES reveals increased need for children's services, issues with managed care and an expansion in the use of the PES as a filter for the mental health system in dealing with substance abuse. Education and research have been added to the missions of the PES and there is strong potential for future development in this area. PESs of the future may be very different, with advances in communication, safety, computerized records and databases. New dilemmas in balancing the patient's right to confidentiality and autonomy against the potential of these advances are bound to occur.

Training issues in emergency psychiatry

The psychiatric emergency service (PES) is an excellent learning environment that offers trainees a multitude of educational opportunities. PES personnel need to develop training programs to ensure that psychiatry residents obtain knowledge and skills in emergency evaluation, crisis management, and triage of patients, as required by accreditation bodies. Curriculum guidelines can best be achieved through a rotation that offers an orientation, didactic presentations, clinical supervision, and graded responsibilities. Improved training opportunities, senior electives, and fellowships will promote emergency psychiatry as a career choice.

[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.

[Compulsory referral to institutionalised psychiatric care and its organizational structure]

Nation-wide German Counseling Review regarding psychiatry in 1975 yielded a reasonable reform of psychiatric care in Germany. Especially outpatient and complementary caring concepts promoted the integration of psychiatric patients in their communities. However, this development was paralled by an increase of involuntary hospitalisations in Northrine-Westphalia. Within ten years involuntary hospitalisations doubled in some communities. These findings contrast with recent concepts of a complex community psychiatry with improved caring according to humanitarian principles and those of non-violence. These specific settings must be taken into consideration in developing community psychiatry. The report presents the activity of the working group concerning community psychiatry in Northrine-Westphalia. During its annual meetings a standardised and valid documentation concerning hospitalisation procedures in the communities as a means of quality control was discussed repeatedly. Taking into consideration the data of this survey the complex mechanisms leading to an increase of involuntary hospitalisations becomes understandable. Health reporting on a community level on the topic of involuntary hospitalisations is an important tool for discussion of its complex psychosocial and administrative mechanisms. Discussion about standard procedures in psychiatric emergency care service will thus be enabled.

[Involuntary admissions in emergency psychiatric institutions. A comparison between the county of Hedmark and the Ullevål sector in Oslo]

In this paper we compare the acute psychiatric wards in Hedmark county and the catchment area of Ullevål hospital with regard to involuntary hospitalizations and admission rates for psychosis during the period 1989-94. In the former area the percentage of involuntary admissions decreased from 58% to 48% during the period, but in the Ullevål catchment area it remained fairly stable at 85%. The latter area showed a higher percentage of involuntary hospitalizations for both psychotic and non-psychotic patients. The admission rate for psychotic patients was higher in the Ullevål catchment area and tended to increase in the course of the study period. We relate our findings primarily to a higher incidence of psychiatric disorders in a city like Oslo. Structural differences in psychiatric and primary care, especially for long-term patients may also be a contributory factor.

Definitive treatment in the psychiatric emergency service

This article briefly reviews the history of psychiatric emergency services (PES) in the United States and concludes that the dominant model, the triage model, unnecessarily limits modern PES. Trends in the mental health system and the corresponding development of compensatory PES structures are described. These include observation units, outreach, and crisis residential treatment and other innovations. These new structures have had the effect of increasing the length of stay in emergency services, increasing the number and complexity of services provided in the PES and professionalizing emergency service personnel. A new model, the treatment model, is proposed for this type of PES. Strategies for the rapid initiation of definitive treatment of bipolar disorder, schizophrenia, major depression and opiate addiction are outlined for services with this capability.