Psychiatric Annals

Feature Article Free

Emergency Psychiatry: How Far Have We Come?

Nidal Moukaddam, MD, PhD; Ali Shah; Asim A. Shah, MD

Abstract

The practice of emergency psychiatry is complex, rich, and rewarding. Emergency psychiatry provides a unique opportunity to experience cases related to novel drugs of abuse and to identify maltreatment, domestic/intimate partner violence, and even human trafficking. The general principles of psychiatric emergency practice include flexible evaluation styles in terms of setting and duration of encounters, targeted prescribing, and readiness for interactions with other specialties, law enforcement, and community mental health providers. The specific needs of the emergency department (ED) patient population, especially related to social context and substance use, need to be taken into account for a successful practice. Two populations/presentations of particular relevance in the ED are patients with contingent suicidality and those with repeat visits/high resource use. High burnout rates secondary to prevalent agitation, unpredictable presentations, and even violence, are endemic to emergency psychiatry practice and need to be carefully managed. [Psychiatr Ann. 2018;48(1):63–68.]

Abstract

The practice of emergency psychiatry is complex, rich, and rewarding. Emergency psychiatry provides a unique opportunity to experience cases related to novel drugs of abuse and to identify maltreatment, domestic/intimate partner violence, and even human trafficking. The general principles of psychiatric emergency practice include flexible evaluation styles in terms of setting and duration of encounters, targeted prescribing, and readiness for interactions with other specialties, law enforcement, and community mental health providers. The specific needs of the emergency department (ED) patient population, especially related to social context and substance use, need to be taken into account for a successful practice. Two populations/presentations of particular relevance in the ED are patients with contingent suicidality and those with repeat visits/high resource use. High burnout rates secondary to prevalent agitation, unpredictable presentations, and even violence, are endemic to emergency psychiatry practice and need to be carefully managed. [Psychiatr Ann. 2018;48(1):63–68.]

The first mention of an emergency psychiatry service was in 1965.1 The author noted that “40% were diagnosed as psychotic and 35% as neurotic,” and the rate of inpatient hospitalization was approximately 20%.1 This next mention is by a psychiatry teaching service in the United States in 1968.2 Although this was more than 50 years ago, the differences between psychiatric emergency practice and more traditional psychiatry still persist. “Philosophies, not law, determine admission practices” was the title of a thought-provoking article from that era,3 and this sentiment is still true today. Emergency psychiatry quickly became the “go-to” resource to fill the gap left by weakening and failing community health systems; in 2017, running a psychiatric emergency service is no longer a luxury or a teaching experience, but a necessity in the face of shrinking health care resources and resulting increased financial and operational pressures. Psychiatrists have become a part of the emergency department (ED) team, and changes to psychiatric practice accompany that inclusion. In this article we trace the evolution of emergency psychiatry, which was previously viewed as an extension of community psychiatry, as a distinct subspecialty. We also note the parallels and main differentiating aspects for this intriguing and highly rewarding area.

What Is Emergency Psychiatry?

The American Association of Emergency Psychiatry (AAEP), founded in the mid 1980s, defines emergency psychiatry as “the clinical application of psychiatry in emergency settings. Conditions requiring psychiatric interventions may include attempted suicide, substance abuse, depression, psychosis, violence or other rapid changes in behavior.”4 To get to that stage, psychiatry had to evolve as a specialty as well as address the need for 24-hour services, the need for teaching in the ED setting, and the conflict between perfectionism and the constraints of modern health care.

What makes an effective, successful emergency psychiatrist? The ability to conduct thoughtful, yet efficient assessments, and to connect the patient with appropriate resources and feasible interventions is an integral part. Some perceptions of emergency psychiatry are negative. As a specialized field, emergency psychiatry has responded to failing community health systems with an increase in short-term admissions and intensive courses of treatment that focus on modifiable factors rather than deep-seated psychiatric pathology, and although many of these changes were the product of adaptations to health care system challenges, some of these structural differences may be beneficial and useful. One widely cited study points out that nonemergency psychiatric practitioners could predict correct disposition of patients with mental illness in the ED only approximately 50% of the time, thus highlighting the expertise of the emergency psychiatrist.5 The set-up of multidisciplinary teams has benefitted patients, as reflected in surveys of patients' opinions.6 Access to emergency psychiatrists may also be instrumental in better resource use in terms of admission versus transition to outpatient management, especially in child and adolescent populations with mental illness.7 It is hypothesized that psychiatric training allows assessment and identification of potential self-harm and first-break psychosis despite use of substances.8 In a study by Rufino et al.,9 it was shown that ED diagnoses upon discharge were highly accurate in psychotic disorders.

Tenets of Practice in Emergency Psychiatry

Frequent Interactions with Nonpsychiatric Specialties and Community Health

The typical emergency psychiatry practice is set up within the larger ED. Some comprehensive psychiatric emergency programs (CPEP) are free-standing, but they typically have ongoing relationships with medical EDs for patients with acute medical issues.

In the traditional transition to inpatient psychiatric units, the psychiatrist would receive a patient from the medical floor or ED with fairly minimal communication; a patient is either accepted or not to the unit after review of clinical information. In contrast, a typical psychiatry consult in the ED is much more involved. Ideally, a dynamic co-management path ensures best patient outcomes. However, the reader should note that as ED boarding times have risen steadily,10 the bulk of medical instability is now dealt with in the psychiatric ED setting. Events related to alcohol and sedative/hypnotic withdrawal symptoms, and behavioral outbursts of manic or psychotic patients who are not yet stabilized are two examples of acute emergencies that represent daily challenges in emergency psychiatry practice. In a context of bed shortage, patients effectively spend the initial phase of admission in the psychiatric ED. The immediate consequence of this clinical landscape is that the emergency psychiatrist has to collaborate with emergency physicians and law enforcement officers on regular basis.

The most common area of lack of consensus and potential disagreement is that of medical clearance or medical stabilization prior to transfers to inpatient psychiatry. Inpatient psychiatric facilities typically require a panel of laboratory tests to be obtained prior to transfer, whereas emergency physicians are taught and encouraged to aim for focused evaluations and testing as necessary. According the AAEP guidelines, “Emergency physicians should work cooperatively with psychiatric receiving facilities to decrease unnecessary testing while increasing the quality of medical screening examinations for psychiatric patients who present to EDs.”11 For the emergency psychiatrist, this represents an ongoing, daily challenge as he or she mediates between inpatient psychiatry and emergency medicine.

Lastly, emergency psychiatry frequently has interactions with law enforcement on multiple levels: agitated, severely ill patients are brought in involuntarily at alarmingly high rates (at the authors' institution, almost one-quarter of patients with a psychiatric chief complaint are brought in by police, and when ambulance and fire department transports are taken into account, the rate rises to almost 50%). Dealings with law enforcement officers, who are neither hospital employees nor family of patients, may be subject to ethical and confidentiality restrictions.12 Once that hurdle is successfully cleared, involuntary commitment laws vary widely from state to state, with only nine states requiring a judge's signature prior to admission,13 and the physician must be familiar and at ease with legal requirements and duty to warn applicable to their states. Once a decision to admit is made, patients often have to wait until a bed is available, a situation known as boarding. ED boarding has many disastrous consequences, including the possibility that a patient will be kept in the ED with no actual treatment despite highly acute mental symptomatology.9 The interface with the law in this aspect is the legality or lack thereof of such measures, highlighted recently by a case in Washington state.14

Thoughtful and Targeted Prescribing

Mental illness is typically the product of complex interactions between nature and nurture. With the exception of substance-induced symptomatology, mental illness is typically chronic. This conflicts sharply with the fast-paced rhythm of the psychiatric ED. Thus, another tenet of practice in the psychiatric ED is a creative and varied prescribing pattern.

Pharmacological prescribing, often the only resort in the psychiatric ED, is reflective of the slow pace of psychiatric practice: antidepressants take weeks for full therapeutic effects, and antipsychotics and fast-acting benzodiazepines are frowned upon in an environment rife with substance misuse and diversion. So what are the emergency psychiatrists to do? Firstly, they can re-examine the data. We can use antidepressants as an example of this. Delayed clinical onset of action of antidepressants is understood based on neuroplasticity models such as changes in brain-derived neurotrophic factor levels with subsequent cascading events for intracellular signaling (for an excellent review, see Harmer et al.15). However, early onset of action of antidepressants often corresponds to full remission rates later, and this is thought to be related to reversal of negative affective bias with antidepressant use and can occur as early as the first week,16,17 so patients are slightly more positive in their assessment of faces, individual people, and situations. Many CPEPs resort to a modality that is intermediate between a full admission and a discharge; although it carries different names (an observation stay, a brief stay, a reassessment), such brief stays can relieve high volumes in the ED but also allow patients to get started in treatment and stabilized, often with improvement.18 In this scenario, a change in practice and patient flow created out of necessity may be proven to be of moderate benefit. As new antidepressant classes of drugs are discovered, such as those with glutamatergic mechanisms, (eg, ketamine19), paradigm shifts in the treatment of mental health complaints in the ED may occur.

The second prescribing dilemma faced by emergency psychiatrists is whether to treat symptomatology that is likely substance-induced. Guidelines for treatment usually recommend deferring initiation of pharmacological treatment in such cases. However, in the ED setting, medications are often started more proactively than in other settings, and doses may be increased rapidly in cases of brief observation. This divergence in practice is a notable difference in emergency psychiatry compared with outpatient psychiatry.

Novelty in Emergency Psychiatry: Expect the Unexpected

Work in the ED is consistently rated as one of the most interesting rotations for physicians-in-training because of case variety, concomitant medical etiologies that mimic or mask psychiatric conditions, and novelty, so the third tenet of emergency psychiatry is to be prepared to approach cases with an open mind and a wide differential diagnosis. Typically, this revolves around substance-related disorders; new illicit drugs are often first recognized in emergency departments when adverse health sequelae begin to be identified, such was the case with the rise of synthetic cannabinoids in 2008.20 Emergency psychiatry also faces challenges from older drugs such as amphetamines, which are now ranked as the second most-used drug class worldwide and that are known to induce psychotic symptoms. Stimulant-related cases are highly prevalent in emergency services,21 and unfortunately there are no effective, time-saving management options. Newer drugs can imitate older compounds and may be easily confused, potentially leading to mistreatment, as in the case of N-benzylphenethylamine, which is sold in the streets as lysergic acid diethylamide (LSD), but can be distinguished by its metallic taste (LSD is tasteless and odorless).

The ED is also a prime environment to uncover emergency social situations such as intimate partner violence or domestic violence, child maltreatment, and human trafficking.22,23 In the course of routine testing in the ED, patients may also learn they are pregnant or have HIV. The scenarios are endless, but the flexibility required from the emergency psychiatrist is key in successfully resolving each case.

Flexible Evaluation Style: Got Time?

The fourth tenet of emergency psychiatry practice revolves around evaluation style. The ED is not the ideal setting for calm, detailed interviews, but many patients presenting with psychiatric chief complaints have complex psychosocial histories and several social stressors that may exacerbate their presentations. Surviving as an emergency psychiatrist requires the ability to conduct interviews within short time constraints, during high symptom acuity, and with frequent interruptions. Overall duration for face-to-face encounters with providers was less than 13 minutes in more than one-half the cases in one study,24 and it is estimated that residents in the ED get interrupted approximately 11 times per hour.25

One further issue with interviews in the ED is the presence of repeat visits from the same patients. Variously termed “high utilizers,” and “frequent flyers,” this is a specific patient population that gets treatment almost exclusively from the ED and presents with high rates of substance use and social stressors, including homelessness.26–30 This population represents a significant challenge for evaluations, testing, and treatment because the rates of nonadherence to treatment are elevated. With repeat visits, patients may not get complete testing, and interviews may be curtailed to minimal questioning with subsequent potential pitfalls in treatment. Multidisciplinary team approaches are invaluable in such cases for information gathering and for help with belligerence and lack of cooperation.31

Pitfalls and Challenges

No discussion of emergency psychiatry would be complete without a discussion of burnout, bias, and countertransference. Burnout, a trifecta of emotional exhaustion, desensitization and detachment, and cynicism with a negative outlook on one's profession, is especially high in ED settings and contributes to high job turnover and career dissatisfaction. The ED setting has several patient populations that are notoriously difficult to deal with and are often the culprits in burnout in the ED practitioner.

Contingent Suicidality

Frequently dealing with suicidal ideations and threats is thought to be a contributing factor for desensitization and possibly physician burnout. Although studies have long focused on the biological antecedents of suicide, the emergency psychiatrist is faced with raw misery, with outpouring of details regarding socio-economic stressors32 that physicians are unable to change, and this repeated exposure may possibly represent a path toward dehumanization of patients. It is estimated that approximately 4% of ED patients present with a psychiatric chief complaint, and more than one-half of those report suicidal ideations.33 The ED setting presents real opportunities for reducing suicide risk and making a change in the course of patients' lives,34 but interventions known to reduce self-harm35 are neither incorporated nor studied in ED settings.

Contingent suicidality represents the threat of suicidal action when the patient does not get what they ask for. This is often related to housing resources but may also be related to narcotic or other prescriptions for controlled substances, pain management, or other requests. The challenges of this population include high liability in case of an adverse event, increased desensitization to suicidal statements in the physician (with ensuing doubt, guilt, and intense countertransference feelings), and the significant risk of missing true suicidal potential.

“High Utilizers” or “Frequent Flyers”

Emergency psychiatry is at the forefront of changes in community health and as such, has to be flexible and adaptable. Deinstitutionalization of state-run psychiatric hospitals has brought about multiple changes to the structure of psychiatric treatment in all affected countries, but has not affected stigma about mental illness.36,37 A specific group of patients, pejoratively referred to as “frequent flyers,” and more correctly as “high utilizers,” represents a subpopulation with repeat ED resource use and marked nonadherence to treatment recommendations. Most psychiatrists agree that we should avoid the term “frequent flyers,” as it is not only derogatory but also does not clearly reflect the time spent on these patients. Many high utilizers may be homeless, addicted to illegal substances, have personality disorders or developmental delays, be enrolled in a mental health plan, have a history of psychiatric hospitalizations, have unreliable social support, and have a lifetime history of incarceration and detoxification.38 There is one category of high utilizers that is purely medical (multiple medical comorbidities and decompensation [eg, congestive heart failure]), and the challenging psychiatry ED population, such as people with comorbid substance use disorders, severe mental illness, and high rates of child maltreatment and trauma.39,40

Compared to the 1960s and 1970s, more people with mental illness now seek care in the ED or in primary care offices,41 but inpatient beds are scarce. The people who seek care in those settings have higher distress levels than the population described in the 1960s.42 Nevertheless, people have a better quality of life outside institutions but may suffer undertreatment, especially when homeless,42 whereas they fare quite well when surrounded with high-level care such as assertive community treatment services.43 Most of the high utilizers in urban or poor communities, however, do not have access to such resources. In recent years, the landscape of health care policy has changed, with increased attention to the need for housing to give any other treatment a chance to be effective. As the community health field starts to appreciate the importance of dealing with homelessness first,44 the face of emergency psychiatry may change again.

Management of Countertransferential Feelings

The intensity of presentations in the ED promotes strong countertransference (CT) feelings in anyone providing care. The psychodynamic concept of CT was coined by Freud and referred to feelings the providers had toward their patients.45 In the ED, however, the clinical face-to-face encounters are short in duration and are different than traditional office visits; repeat visits only occur with specific subpopulations of high utilizers (described above) and are often loaded with negative CT feelings related to helplessness, inability to help the patient, and frustration that the patient has not followed through on the last treatment recommendations (such as referrals to substance use programs). Agitation and violence are also a commonly encountered problem in the ED,46 and may well be one of the most prominent factors in high staff turnover and burnout in ED settings. These instances of violence carry potential for injury to patient and staff.

The concept of instant countertransference (iCT) has been coined to describe feelings that occur in such situations.47 There is much that needs to be understood about how provider feelings affect management, especially in complicated patients in the ED. The influence of iCT on physician engagement in referrals and elaborate discharge planning, as well as with coercive incidents including use of seclusion and restraints, has not been studied.

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Authors

Nidal Moukaddam MD, PhD, is an Associate Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Ali Shah is an Undergraduate Student, College of Natural Science, University of Houston. Asim A. Shah, MD, is a Professor and the Vice Chair for Community Psychiatry, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; and the Chief of Psychiatry, Ben Taub Hospital, Harris Health System.

Address correspondence to Nidal Moukaddam, MD, PhD, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, NPC, 2nd Floor, 1504 Taub Loop, Houston, TX 77030; email: nidalm@bcm.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20171128-01

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