Emergency Psychiatry - Clinical Application of Psychiatry in Emergencies

Emergency psychiatry is the clinical application of psychiatry in emergency situations. Conditions requiring psychiatric intervention may include attempted suicide, substance abuse, depression, psychosis, violence, or other rapid behavioral changes. Emergency psychiatric services are provided by specialists in medicine, nursing, psychology and social work. The demand for psychiatric emergency services has grown rapidly worldwide since the 1960s, especially in urban areas. The care of patients in psychiatric emergencies is complex.

Individuals may enter the mental health emergency service voluntarily, by referral from another health care provider, or involuntarily. Care for patients requiring psychiatric intervention typically involves crisis stabilization of many serious and potentially life-threatening conditions, which may include acute or chronic mental disorders or symptoms similar to these conditions.

Definition

Symptoms and conditions underlying psychiatric emergencies may include suicide attempts, substance dependence, alcohol intoxication, acute depression, presence of delusions, violence, panic attacks, and significant, rapid changes in behavior. Emergency psychiatry exists to identify and/or treat these symptoms and psychiatric conditions. In addition, some medical conditions with rapid fatalities exhibit common psychiatric symptoms. The ability of the physician or nurse to identify and intervene with these and other medical conditions is critical.

Provision of services

Places where mental health emergency services are provided are most commonly referred to as mental health emergency services, mental health emergency centers, or comprehensive mental health emergency programs. These facilities are staffed by mental health professionals from a wide range of disciplines, including medicine, nursing, psychology, and social work, in addition to psychiatrists and emergency physicians. These facilities, sometimes housed in a psychiatric hospital, psychiatric ward or emergency room, provide immediate treatment for both voluntary and involuntary patients 24 hours a day, 7 days a week.

In a sheltered environment, psychiatric emergency services exist to provide short stays of two to three days to obtain diagnostic clarity, to find suitable alternatives to psychiatric hospitalization for the patient, and to treat those patients whose symptoms can be improved during this short period of time. Even accurate psychiatric diagnoses are a secondary priority to crisis intervention. The functions of the psychiatric emergency service are to assess patient problems, provide short-term treatment consisting of no more than ten patient encounters, provide 24-hour room, mobilize teams for interventions in the patient's residence, use emergency management services to prevent further crises, awareness of inpatient and outpatient psychiatric resources, and 24-hour telephone counseling.

History

Since the 1960s, the demand for acute psychiatric care services has grown rapidly due to deinstitutionalization in both Europe and the United States. Deinstitutionalization in some places has resulted in more seriously mentally ill people living in the community. The number of medical specialties has increased, as have the number of transient treatment options, such as psychiatric drugs. The actual number of psychiatric emergencies has also increased significantly, especially in psychiatric emergency services located in urban areas.

Emergency psychiatry includes assessment and treatment of the unemployed, homeless and other disenfranchised populations. Emergency psychiatry services can sometimes offer accessibility, convenience and anonymity. Although many of the patients who used psychiatric emergency services shared sociological and demographic characteristics, symptoms and needs did not fit any single psychiatric profile. Individualized care for patients using mental health emergency services has evolved, requiring an ever-changing and sometimes complex approach to treatment.

Suicide Attempts and Suicidal Thoughts

According to the World Health Organization in 2000, there are one million suicides per year in the world. Suicide attempts are countless. Psychiatric emergency services exist to treat mental disorders associated with an increased risk of suicide or attempted suicide. Mental health professionals in these facilities are expected to predict acts of violence that patients may commit against themselves (or others), even though the set of factors that lead to suicide may be due to many causes, including psychosocial, biological, interpersonal, anthropological, and religious. These mental health professionals will use all resources available to them to identify risk factors, make an overall assessment, and decide on any necessary treatment.

Violent behavior

Aggression can result from both internal and external factors that create a measurable activation in the autonomic nervous system. This activation may manifest as symptoms such as clenching of fists or jaws, staggering, slamming doors, slamming palms with fists, or mild frightening. It is estimated that 17% of mental health emergency services referrals have homicidal overtones, and another 5% are related to both suicide and homicide. Violence is also associated with many conditions, such as acute intoxication, acute psychosis, paranoid personality disorder, antisocial personality disorder, narcissistic personality disorder, and borderline personality disorder. Additional risk factors that can lead to violent behavior have also been identified. These risk factors could include previous arrests, having hallucinations, delusions or other neurological disorders, being uneducated, being unmarried, etc. Mental health professionals conduct a violence risk assessment to determine safety measures and treatment for the patient.

Psychosis

Patients with psychotic symptoms are frequently seen in psychiatric emergency services. Determining the source of psychosis can be difficult. Sometimes patients brought to the facility in a psychotic state have been disconnected from a previous treatment plan. Although the mental health emergency service will not be able to provide long-term care for such patients, it can provide short-term respite care and reunite the patient with his or her supervisor and/or resume necessary psychiatric medications. A visit to the crisis unit by a patient with a chronic mental health disorder may also indicate the presence of an undetected precipient, such as a change in the person's lifestyle or a change in health status. These considerations may play a role in improving an existing treatment plan.

A person may also experience an acute attack of psychosis. Such conditions can be prepared for diagnosis by collecting the patient's medical or psychopathological history, conducting a mental status examination, psychological testing, and obtaining neuroimaging and other neurophysiological measurements. The mental health professional can then make a differential diagnosis and prepare the patient for treatment. As with other patient care issues, the origin of acute psychosis can be difficult to determine because of the patient's mental state. Nevertheless, acute psychosis is classified as a medical emergency requiring immediate and full attention. Lack of identification and treatment can lead to suicide, homicide, or other violence.

Substance dependence, abuse and intoxication

Another common cause of psychotic symptoms is substance intoxication. These acute symptoms may go away after a period of observation or limited psychopharmacological treatment. However, underlying problems, such as substance dependence or abuse, are difficult to treat in the emergency room because it is a long-term condition. Both acute alcohol intoxication and other forms of substance abuse may require psychiatric intervention. Acting as a central nervous system depressant, the early effects of alcohol are usually welcome and characterized by increased talkativeness, dizziness, and weakened social inhibitions. In addition to considerations of impaired concentration, verbal and motor activity, discernment, judgment, and short-term memory loss, which can lead to changes in behavior that cause injury or death, levels of alcohol below 60 milligrams per deciliter of blood are generally considered nonlethal. However, individuals with concentrations of 200 milligrams per deciliter of blood are considered severely intoxicated, and concentrations of 400 milligrams per deciliter of blood are fatal, causing complete anesthesia of the respiratory system.

In addition to the dangerous behavioral changes that occur after consuming a certain amount of alcohol, some people may experience idiosyncratic intoxication even after consuming relatively small amounts of alcohol. Episodes of this disorder usually consist of confusion, disorientation, delirium and visual hallucinations, increased aggression, rage, agitation and violence. Chronic alcoholics may also experience alcoholic hallucinosis, in which cessation of prolonged alcohol consumption may cause auditory hallucinations. Such episodes can last as long as a few hours or as long as a week. Antipsychotics are often used to treat these symptoms.

Patients can also be treated for substance abuse after taking psychoactive substances containing amphetamine, caffeine, tetrahydrocannabinol, cocaine, phencyclidines or other inhalants, opioids, sedatives, hypnotics, anxiolytics, psychedelics, dissociatives and deliriants. Clinicians evaluating and treating substance abusers must establish a therapeutic rapport to counteract denial and other negative attitudes toward treatment. In addition, the clinician must determine the substances used, method of ingestion, dosage, and time of last use in order to determine the short- and long-term treatment needed. An appropriate treatment site must also be selected. This may be outpatient facilities, partial hospitals, community treatment centers, or hospitals. Both short- and long-term treatment and conditions are determined by the severity of the addiction and the severity of the physiological complications resulting from the abuse.

Dangerous drug reactions and interactions

Overdoses, drug interactions, and dangerous reactions from psychiatric drugs, especially antipsychotics, are considered psychiatric emergencies. Neuroleptic malignant syndrome is a potentially fatal complication of first- or second-generation antipsychotics. Untreated, neuroleptic malignant syndrome can lead to fever, muscle rigidity, confusion, unstable vital signs, or even death. Serotonin syndrome can occur when selective serotonin reuptake inhibitors or monoamine oxidase inhibitors are mixed with buspirone. Severe symptoms of serotonin syndrome include hyperthermia, delirium, and tachycardia, which can lead to shock. Often patients with severe general medical symptoms, such as unstable vital signs, are transferred to a general emergency department or medical service for enhanced monitoring.

Personality disorders

Disorders manifesting dysfunction in areas related to cognition, affectivity, interpersonal functioning, and impulse control may be considered personality disorders. Patients with a personality disorder usually do not complain of symptoms caused by their disorder. Patients with the emergency phase of a personality disorder may exhibit combative or suspicious behavior, have brief psychotic episodes, or have delusions. Compared to outpatient settings and the general population, the prevalence of persons with personality disorders in inpatient psychiatric settings is typically 7-25% higher. Clinicians working with such patients attempt to stabilize the individual to baseline levels of functioning.

Anxiety

Patients with an extreme case of anxiety may seek treatment when all support systems are exhausted and they are unable to tolerate the anxiety. Anxiety can manifest in a variety of ways: as a consequence of an underlying medical illness or psychiatric disorder, as a secondary functional impairment in another psychiatric disorder, as a consequence of a primary psychiatric disorder such as panic disorder or generalized anxiety disorder, or as a result of stress in conditions such as adjustment disorder or posttraumatic stress disorder. Clinicians usually try to provide a "safe harbor" for the patient first so that assessment and treatment can be adequately conducted. The initiation of treatment for mood and anxiety disorders is very important because patients with anxiety disorders have a higher risk of premature death.

Disasters

Natural disasters and man-made hazards can cause severe psychological distress to victims surrounding the event. Emergency management often includes the provision of psychiatric emergency care to help victims cope with the situation. The aftermath of disasters can cause people to feel shocked, depressed, immobilized, panicked, or confused. In the hours, days, months or even years after a disaster, people may experience distressing memories, vivid nightmares, apathy, withdrawal, memory lapses, fatigue, loss of appetite, insomnia, depression, irritability, panic attacks or dysphoria.

Because of the usually disorganized and dangerous post-disaster environment, mental health professionals usually assess and treat patients as quickly as possible. If the condition is not life-threatening for the patient or those around them, other medical and survival issues are addressed first. Shortly after a disaster, physicians may provide an opportunity to ventilate the room to alleviate feelings of isolation, helplessness and vulnerability. Depending on the extent of the disaster, many survivors may develop chronic or acute post-traumatic stress disorder. Patients suffering from this disorder in its severe form are often admitted to psychiatric hospitals to stabilize their condition.

Incidents of physical abuse, sexual assault or rape can lead to dangerous consequences for the victim of the criminal act. Victims may experience intense anxiety, fear, helplessness, confusion, eating or sleeping disorders, hostility, guilt and shame. Response management usually involves the coordination of psychological, medical and legal aspects. Depending on legal requirements in the region, mental health professionals may be required to report criminal activity to the police. Mental health professionals usually collect identifying information during the initial assessment and refer the patient for medical treatment if necessary. Medical treatment may include a physical examination, collection of medical and forensic evidence, and determination of pregnancy risk, if applicable.

Treatment

Treatment in the psychiatric emergency service is usually temporary and exists only to provide dispositional solutions and/or stabilization of life-threatening conditions. Once stabilized, patients with chronic conditions may be transferred to a facility that can provide long-term psychiatric rehabilitation. Prescribed treatments in the acute care setting depend on the patient's condition. Various forms of psychiatric medications, psychotherapy or electroconvulsive therapy may be used in the acute care setting. The introduction and effectiveness of psychiatric medications as a treatment modality in psychiatry has reduced the use of physical restraints in the acute care setting by reducing dangerous symptoms resulting from exacerbation of mental illness or substance intoxication.

Medications

Pharmacokinetics is the movement of drugs through the body over time and depends at least in part on the route of administration, absorption, distribution, and metabolism of drugs. Oral administration is a common route of administration, but in order for this method to work, the drug must get into the stomach and stay there. In cases of vomiting and nausea, this method of administration is not appropriate. In some situations, suppositories may be used instead. The medicine can also be given by intramuscular or intravenous injection.

The time needed for absorption depends on many factors, including the solubility of the medication, gastrointestinal motility, and pH. If the medication is taken orally, the amount of food in the stomach can also affect the rate of absorption. Once absorbed, the medication must be distributed throughout the body or, usually in the case of psychiatric drugs, cross the blood-brain barrier and reach the brain. Because all of these factors affect the rapidity of onset of effect, the time to effect can vary. In general, however, the time to effect of medications is relatively quick and can occur within minutes. Antipsychotics, especially haloperidol, and various benzodiazepines are the most commonly used drugs in emergency psychiatry, especially for agitation.

Psychotherapy

Other therapies may also be used in the psychiatric emergency service setting. Brief psychotherapy can be used to treat acute conditions or urgent problems provided the patient understands that his or her problems are psychological, the patient trusts the physician, the physician can instill hope for change, the patient is motivated to change, the physician is aware of the patient's psychopathological history, and the patient understands that his or her confidentiality will be respected. The process of brief psychotherapy for psychiatric emergencies includes establishing the patient's chief complaint, becoming aware of psychosocial factors, formulating an accurate representation of the problem, coming up with solutions to the problem, and setting specific goals. Gathering information in brief psychotherapy is therapeutic in that it helps the patient put his or her problem in the right perspective. If the therapist decides that more in-depth psychotherapy sessions are needed, he or she can transfer the patient from the emergency department to an appropriate clinic or center.

Electroconvulsive therapy is a controversial form of treatment that cannot be administered involuntarily in a psychiatric emergency setting. In cases where the patient is so severely depressed that he or she cannot be stopped from harming himself or herself, or when the patient refuses to swallow, eat, or drink medication, electroconvulsive therapy may be offered as a therapeutic alternative. Although preliminary studies show that electroconvulsive therapy can be an effective treatment for depression, it usually takes a course of six to twelve sessions of convulsions lasting at least 20 seconds for an antidepressant effect to occur.

Surveillance and related information

There are other essential aspects of acute psychiatry: observation and related information. Observation of the patient's behavior is an important aspect of emergency psychiatry because it allows clinicians working with the patient to assess prognosis and improvement/deterioration. In many jurisdictions, the basis for involuntary hospitalization is the danger or inability to care for one's basic needs. Observation over a period of time can help determine this. For example, if a patient who is incarcerated for aggressive behavior in the community continues to behave erratically and without a clear goal, it will help the staff decide if hospitalization is necessary.

Related or concurrent information is information obtained from the patient's family, friends, or treatment providers. Some jurisdictions require patient consent to obtain such information, others do not. For example, if a patient believes he or she is paranoid or is being followed or spied on, this information can help determine whether those thoughts are true. Past episodes of suicide attempts or aggressive behavior can be confirmed or denied.

Disposal

The patient receives emergency services often for a limited time, such as 24 or 72 hours. After that time, and sometimes sooner, staff must decide where the patient will receive services in the future. This is called disposition. This is one of the main features of emergency psychiatry.

Hospitalization

The staff must determine if the patient needs to be admitted to a psychiatric hospital or can be safely discharged into the community after a period of observation and/or short-term treatment. Initial emergency psychiatric evaluations are usually performed for patients with acute agitation, paranoia, or suicidal ideation. Initial assessments to determine hospitalization and intervention should be as therapeutic as possible.

Compulsory obligation

Involuntary hospitalization, or sectionalization, refers to situations where police officers, medical professionals or health care professionals classify a person as dangerous to self, others, seriously ill or mentally ill according to applicable state law in the area. Once a person is transported to a mental health emergency room, a preliminary professional evaluation is conducted, which may or may not result in involuntary treatment. Some patients may be discharged shortly after being transported to the mental health emergency service, while others will require longer observation and will require further involuntary treatment. Although some patients may initially come voluntarily, they may be found to be a danger to themselves or others, at which point compulsory treatment may be initiated.

Referral for hospitalization and voluntary hospitalization

In some countries, such as the United States, voluntary hospitalizations exceed involuntary hospitalizations, in part because insurance generally does not pay for hospitalization unless there is an immediate danger to the individual or society. In addition, psychiatric emergency services admit about one-third of patients from community-based assertive treatment centers. Therefore, patients who have not been hospitalized will be referred for services in the community.

Links

1. ^ Currier, G.W.. New Developments in Emergency Psychiatry: Medical, Legal, and Economic. (1999). San Francisco: Jossey-Bass Publishers.
2. ^ Hilliard, R. & Zietek, B. (2004). Emergency psychiatry. New York: McGraw-Hill.
3. ^ Bassuk, E.L. & Birk, A.W.. (1984). Emergency Psychiatry: Concepts, Methods, and Practices. New York: Plenum Press.
4. ^ Lipton, F.R. & Goldfinger, S.M. (1985). Emergency psychiatry at a crossroads. San Francisco: Jossey-Bass Publishers.
5. De Clercq, M.; Lamarre, S.; Vergouwen, H. (1998). Emergency psychiatry and mental health policy: An international perspective. New York: Elsevier.
6. ^"Glossary. U.S. News & World Report. Retrieved 2007-07-15.
7. ^ "Crisis Service." NAMI-San Francisco. Archived 2007-07-10 from the source. Retrieved 2007-07-15.
8. ^ Currier GW (Mar 2003). "Organization and function of academic acute care psychiatric services". General Hospital Psychiatry. 25 (2): 124–129. doi:10.1016/s0163-8343(02)00287-6. PMID 12676426. Retrieved 4 Oct 2020.
9. Allen, M.H. (1995). The growth and specialization of acute psychiatry. San Francisco: Jossey-Bass Publishers.
10. Hilliard, J.R. (1990). Handbook of clinical emergency psychiatry. Washington, DC: American Psychiatric Press.
11. ^ Hedges, D. & Burchfield, C. (2006). Mind, Brain, and Drugs: An Introduction to Psychopharmacology. Boston: Pearson Education.
12. ^ GersonS, Bassuk E (1980). "Psychiatric emergencies: a review". American Journal of Psychiatry. 137 (1): 1-11. doi:10.1176/ajp.137.1.1. PMID 6986089.
13. ^ Suicide Prevention (SUPRE). World Health Organization. Archived from the source on 2004-07-01. Retrieved 2007-08-11.
14. ^ HughesDH(1996). "Evaluation of suicide and violence in psychiatry". General Hospital Psychiatry. 18 (6): 416-21. doi:10.1016/S0163-8343(96)00037-0. PMID 8937907.
15. American PsychiatricAssociation. (2000). Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition. Washington, DC: American Psychiatric Publishers.
16. ^ Walker, J. I. (1983) Psychiatric emergencies. Philadelphia: J.B. Lippincott.
17. ^ Rund, D.A., & Hutzler, J.C. (1983). Emergency psychiatry. St. Louis: The C.V. Mosby Company.
18. ^ Potter, M. (2007, May 31). Standard Setting: Human Rights and Health - Mental Health. Northern Ireland Human Rights Commission.
19. ^ HolfordN.H.G.; Sheiner L.B. (1981). "In vivo pharmacokinetic and pharmacodynamic modeling". CRC Critical Reviews in Bioengineering. 5 (4): 273-322. PMID 7023829.
20. ^ Wilson, M. P.; Pepper, D; Currier, G. W.; Holloman Jr, G. H.; Feifel, D (2012). "Psychopharmacology of agitation: consensus statement of the American Psychiatric Emergency Psychiatry Association BETA Project psychopharmacology working group". Western Journal of Emergency Medicine. 13 (1): 26-34. doi:10.5811/westjem.2011.9.6866. PMC 3298219. PMID 22461918.
21. ^ Wilhelm, S; Schacht, A; Wagner, T (2008). "Use of antipsychotics and benzodiazepines in patients with psychiatric emergencies: Results of an observational study". BMC Psychiatry. 8: 61. doi:10.1186/1471-244X-8-61. PMC 2507712. PMID 18647402..

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