Emergency psychiatry is the clinical application of psychiatry in emergency settings. Conditions requiring psychiatric interventions may include suicide attempts, substance abuse, depression, psychosis, violence, or other rapid changes in behavior.
Psychiatric emergency services are rendered by professionals in the fields of medicine, nursing, psychology, and social work. The demand for emergency psychiatric services has rapidly increased throughout the world since the 1960s, especially in urban areas. Care for patients in situations involving emergency psychiatry is complex.
Individuals may arrive in psychiatric emergency service settings through their own voluntary request, a referral from another health professional, or through involuntary commitment.
Care of patients requiring psychiatric intervention usually encompasses crisis stabilization of many serious and potentially life-threatening conditions which could include acute or chronic mental disorders or symptoms similar to those conditions.
Definition Symptoms and conditions behind psychiatric emergencies may include suicide attempts, parasuicide, substance dependence, alcohol intoxication, acute depression, presence of delusions, violence, panic attacks, and significant, rapid changes in behavior.De Clercq, M.; Lamarre, S.; Vergouwen, H. (1998). Emergency Psychiatry and Mental Health Policy: An International Point of View. New York: Elsevier.
Emergency psychiatry exists to identify and/or treat these symptoms and psychiatric conditions. In addition, several rapidly lethal medical conditions present themselves with common psychiatric symptoms. A physician's or a nurse's ability to identify and intervene with these and other medical conditions is critical.Currier, G.W. New Developments in Emergency Psychiatry: Medical, Legal, and Economic. (1999). San Francisco: Jossey-Bass Publishers.
A psychiatric emergency is a disturbance in thought, mood and/or action which causes sudden distress to the individual and/or others, and/or sudden disability or death, thus requiring immediate management.
Delivery of services The place where emergency psychiatric services are delivered are most commonly referred to as Psychiatric Emergency Services, Psychiatric Emergency Care Centers, or Comprehensive Psychiatric Emergency Programs. Mental health professionals from a wide area of disciplines, including medicine, nursing, psychology, and social work in these settings alongside psychiatrists and emergency physicians.Hillard, R. & Zitek, B. (2004). Emergency Psychiatry. New York: McGraw-Hill. The facilities, sometimes housed in a psychiatric hospital, psychiatric ward, or emergency department, provide immediate treatment to both voluntary and involuntary patients 24 hours a day, 7 days a week.
Within a protected environment, psychiatric emergency services exist to provide brief stay of two or three days to gain a diagnostic clarity, find appropriate alternatives to psychiatric hospitalization for the patient, and to treat those patients whose symptoms can be improved within that brief period of time.Allen, M.H. (1995). The Growth and Specialization of Emergency Psychiatry. San Francisco: Jossey-Bass Publishers. Even precise psychiatric diagnoses are a secondary priority compared with interventions in a crisis setting. The functions of psychiatric emergency services are to assess patients' problems, implement a short-term treatment consisting of no more than ten meetings with the patient, procure a 24-hour holding area, mobilize teams to carry out interventions at patients' residences, utilize emergency management services to prevent further crises, be aware of inpatient and outpatient psychiatric resources, and provide 24/7 telephone counseling.Hillard, J.R. (1990). Manual of Clinical Emergency Psychiatry. Washington D.C.: American Psychiatric Press
History
Since the 1960s, the demand for emergency psychiatric services has endured a rapid growth due to deinstitutionalization both in Europe and the United States. Deinstitutionalization, in some locations, has resulted in a larger number of severely mentally ill people living in the community. There have been increases in the number of medical specialties, and the multiplication of transitory treatment options, such as psychiatric medication.Bassuk, E.L. & Birk, A.W. (1984). Emergency Psychiatry: Concepts, Methods, and Practices. New York: Plenum Press.Lipton, F.R. & Goldfinger, S.M. (1985). Emergency Psychiatry at the Crossroads. San Francisco: Jossey-Bass Publishers.Hedges, D. & Burchfield, C. (2006). Mind, Brain, and Drug: An Introduction to Psychopharmacology. Boston: Pearson Education. The actual number of psychiatric emergencies has also increased significantly, especially in psychiatric emergency service settings located in urban areas.
Emergency psychiatry has involved the evaluation and treatment of unemployed, homeless, and other disenfranchised populations. Emergency psychiatry services have sometimes been able to offer accessibility, convenience, and anonymity. While many of the patients who have used psychiatric emergency services shared common sociological and demographic characteristics, the symptoms and needs expressed have not conformed to any single psychiatric profile. The individualized care needed for patients utilizing psychiatric emergency services is evolving, requiring an always changing and sometimes complex treatment approach.
Scope
Suicide attempts and suicidal thoughts the World Health Organization estimates 727,000 suicides in the world each year. There are many times more suicide attempts. Psychiatric emergency service settings exist to treat the mental disorders associated with an increased risk of suicide or suicide attempts. Mental health professionals in these settings are expected to predict acts of violence patients may commit against themselves (or others), even though the complex factors leading to a suicide can stem from many sources, including psychosocial, biological, interpersonal, anthropological, and religious. These mental health professionals will use any resources available to them to determine risk factors, make an overall assessment, and decide on any necessary treatment.
Violent behavior Aggression can result from internal and external factors that create measurable activation in the autonomic nervous system. This activation can become evident through symptoms such as being easily startled, clenching the fists or jaw, hitting palms of hands with fists, pacing, or slamming doors. It is estimated that 17% of visits to psychiatric emergency service settings are homicidal in origin and an additional 5% involve 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 have also been identified which may lead to violent behavior. Such risk factors may include prior arrests, presence of hallucinations, delusions, or other neurological impairment, being uneducated, unmarried, etc. Mental health professionals complete violence risk assessments to determine both security measures and treatments for the patient.
Psychosis Patients with psychotic symptoms are common in psychiatric emergency service settings. The determination of the source of the psychosis can be difficult. Sometimes patients brought into the setting in a psychotic state have been disconnected from their previous treatment plan. While the psychiatric emergency service setting will not be able to provide long-term care for these types of patients, it can exist to provide a brief respite and reconnect the patient to their case manager and/or reintroduce necessary psychiatric medication. A visit to a crisis unit by a patient with a chronic mental disorder may also indicate the existence of an undiscovered precipitant, such as change in the lifestyle of the individual, or a shifting medical condition. These considerations can play a part in an improvement to an existing treatment plan.
An individual could also be experiencing an acute onset of psychosis. Such conditions can be prepared for diagnosis by obtaining a medical or psychopathological history of a patient, performing a mental status examination, conducting psychological testing, obtaining neuroimages, and obtaining other neurophysiologic measurements. Following this, the mental health professional can perform a differential diagnosis and prepare the patient for treatment. As with other patient care considerations, the origins of acute psychosis can be difficult to determine because of the mental state of the patient. However, acute psychosis is classified as a medical emergency requiring immediate and complete attention according to Shubham kumar. The lack of identification and treatment can result in suicide, homicide, or other violence.
Substance dependence, abuse, and intoxication
Another common cause of psychotic symptoms is substance intoxication. These acute symptoms may resolve after a period of observation or limited psychopharmacological treatment. However the underlying issues, such as substance dependence or abuse, is difficult to treat in the emergency department, as it is a long term condition. Both acute alcohol intoxication as well as other forms of substance abuse can require psychiatric interventions. Acting as a depressant of the central nervous system, the early effects of alcohol are usually desired for and characterized by increased talkativeness, giddiness, and a loosening of social inhibitions. Besides considerations of impaired concentration, verbal and motor performance, insight, judgment, and short-term memory loss, which could result in behavioral change causing injury or death, levels of alcohol below 60 milligrams per deciliter of blood are usually considered non-lethal. However, individuals at 200 milligrams per deciliter of blood are considered grossly intoxicated and concentration levels at 400 milligrams per deciliter of blood are lethal, causing complete anesthesia of the respiratory system.
Beyond the dangerous behavioral changes that occur after the consumption of certain amounts of alcohol, idiosyncratic intoxication could occur in some individuals even after the consumption of relatively small amounts of alcohol. Episodes of this impairment usually consist of confusion, disorientation, delusions and visual hallucinations, increased aggressiveness, rage, agitation, and violence. Chronic alcoholics may also have alcoholic hallucinosis, wherein the cessation of prolonged drinking may trigger auditory hallucinations. Such episodes can last for a few hours or an entire week. Antipsychotics are often used to treat these symptoms.
Patients may also be treated for substance abuse following the administration of psychoactive substances containing amphetamine, caffeine, tetrahydrocannabinol (THC), cocaine, phencyclidine (PCP), inhalants, opioids, sedatives, hypnotics, anxiolytics, and hallucinogens. Clinicians assessing and treating substance abusers must establish therapeutic rapport to counter denial and other negative attitudes directed towards treatment. In addition, the clinician must determine substances used, the route of administration, dosage, and time of last use to determine the necessary short and long-term treatments. An appropriate choice of treatment setting must also be determined. These settings may include outpatient facilities, partial hospitals, residential treatment centers, or hospitals. Both the immediate and long-term treatment and setting is determined by the severity of dependency and seriousness of physiological complications arising from the abuse.
Hazardous drug reactions and interactions