The 20th century introduced a number of new concepts to psychiatry and clinical psychology. One of the most influential has been the notion of personality. Carl Jung, Gordon Allport, Abraham Maslow, Harry Stack Sullivan, and Carl Rogers are just a few of the early figures who, starting in the 1920s, developed theories and models designed to capture the inner core of human subjectivity (or the “self,” as Rogers put it). But while their names and ideas continue to resonate, time has proven less kind to another psychological project that played out at the same time. This was characterology.

Coined in 1867 by Julius Bahnsen, a student of the philosopher Arthur Schopenhauer, characterology was associated primarily with Germany. It is there that it began to take hold and thrive, with the founding of the field’s two major journals in the mid-1920s: 

Jahrbuch fÃ¼r Charakterologie (Yearbook for Characterology)

Zeitschrift fÃ¼r Menschenkunde (Journal for Human Studies)

Characterology emerged as a type of character analysis following along the lines of the clinical assessment of functional disorders in the 19th century. This was an assessment that involved examining a patient for outward signs indicating a psychopathology or at least a proclivity toward some pathological state of mind. The approach was beholden in no small measure to the work of the France-based psychiatrist BÃ©nÃ©dict Morel (1809-1873), whose theory of degeneration held that most mental disorders were due to corrupt hereditary constitutions and that these corruptions were reflected in observable physical stigmata and behavioral abnormalities.

 Characterology’s innovation was to extend this kind of evaluation to populations beyond those deemed “abnormal,” in order to identify those traits that drove an individual’s will and conduct.

In Germany, characterology’s star began rising in the 1920s and 1930s, when industry and the public sector began seeing the value in applied psychology. Both psychotechnics and vocational counseling were beneficiaries of this growing interest. So too was characterology, whose practitioners at the time placed less emphasis on testing and quantitative measures and more on the observation and interpretation of expressions of virtues, such as patience, independence, love of order, and calmness.

How then did characterologists propose doing this?

One way was developed by psychiatrist Ernst Kretschmer (1888-1964), which he laid out in his influential book 

 in 1921. He argued that two types of constitutions-a cyclothymic and a schizothymic-are at the core of human character to varying degrees. Moreover, human beings are born with one of three basic body types: asthenic, pyknic, and athletic, and these body types are closely associated with contrasting pairs of character features. Individuals of the pyknic variety, for instance, he believed, temperamentally fluctuate between joviality and despair. Thus, if Kretschmer’s model was accurate, it was possible to read character features and predilections by simply inspecting a subject’s physique.

Psychologist Ludwig Klages (1872-1956) offered another technique: graphology. The notion that a bodily movement like handwriting could provide direct insight into the soul or character of a person was not new, having been the subject of treatises dating back to at least the 17th century. What Klages and others did by the early 20th century, however, was to tie handwriting directly to neurology, understanding the activity to be a form of expression that projected facets of a person’s inner core.

Klages’s graphology was hardly an innocuous exercise. Instead, it was bound up in the psychologist’s dark vision of the modern world. Like many of his reactionary contemporaries, Klages considered modernity to be dangerously superficial and chaotic in a way that undermined the ability of human beings (and Germans in particular) to fully realize themselves. The world therefore needed a way to differentiate between authenticity and falsehood, between genuine virtue and corrosive subterfuge. Characterology and graphology were therefore conceived as tools capable of breaking through the veneer of a person and exposing his or her true nature.

As historians Per Leo and Nitzan Lebovic have shown, Klages in particular argued for there being a natural, racial inequality separating groups of human beings, one that penetrated deep into the body and mind. Here characterology intersected with the toxic anti-Semitism of its time, holding to the view that Jews literally embodied this inequality, casting them as perpetual outsiders, but ones who disguised their true selves.

 It therefore should come as no surprise that under the Nazis characterology flourished.

It needs to be pointed out, however, that interest in character was not limited to Germany. During World War II, for instance, a number of American cultural anthropologists volunteered their services and knowledge to aid in the war effort against Nazi Germany and Imperial Japan (and they would go on to continue this work during the early years of the Cold War). They engaged in what was referred to as “studies of culture at a distance,” a form of applied anthropology intended to serve the interests of the US and framed as the study of national characteristics. Japan, Germany, Russia, Britain, and Poland, all became subjects for these kinds of analyses, which were subsequently criticized for simplifying complex communities and relations.

One of the most famous anthropologists engaged in this project was Margaret Mead (1901-1978). Among her tasks was to collaborate on an initiative of the Council on Intercultural Affairs in New York City to study the “national character” of Axis powers and, later on, the assimilation of minorities in the US along with “our American character.” Publishing the results of her analysis in 1942 in the book 

, Mead argued for rejecting racist essentialisms about groups, while also insisting on the consistency of certain traits among ethnic communities: environment and upbringing, not blood, were the formative elements in national character. And while she invariably invoked an idea of “whiteness” indebted to European prejudices, she held that Americans distinguished themselves from Europeans by giving everyone in society a chance to realize their full potential, thus making the US a more adaptable society.

 That said, despite contending that Japanese-Americans were essentially American in their make-up and conduct, she and her colleagues appear to have done nothing to speak out or campaign against the forced detention of Japanese-Americans during World War II.

In Europe, after the war, characterologists continued their work throughout the 1950s and early 1960s. But times were changing. As West German researchers and clinicians increasingly turned to the US for inspiration, they found themselves drawn to “trait-and-factor” methods instead. The idea was no longer to uncover supposedly fixed character traits, but rather to identify the general aptitudes, adaptabilities, and interests of a person.

 As a result, a more dynamic and developmental concept of “personality” replaced “character” in academic and professional circles.

Dr Eghigian is Professor of History, Penn State University.

Faces of Degeneration: A European Disorder

, c. 1848-c. 1918. Cambridge: Cambridge University Press; 1993.

 Meskill D. Characterological psychology and the German political economy in the Weimar period (1919-1933). 

 Stanghellini G, Broome M, Raballo A, et al. 

The Oxford Handbook of Phenomenological Psychopathology

. New York; Oxford: Oxford University Press. 2019.

 SchÃ¤fer A. Graphology in German psychiatry (1870-1930). 

The Philosophy of Life and Death: Ludwig Klages and the Rise of Nazi Biopolitics

 Neiburg F, Goldman M. Anthropology and politics in studies of national character. 

 Hazard Jr, AQ. Wartime anthropology, nationalism, and ‘race’ in Margaret Mead’s 

 Mabee C. Margaret Mead and behavioral scientists in World War II: problems in responsibility, truth, and effectiveness. 

 Meskill D. Psychological testing and the German labor market, 1925 to 1965. 

Articles

The 20th century introduced a number of new concepts to psychiatry and clinical psychology. One of the most influential has been the notion of personality.

Before Personality: Character Assessment and Its Troubled History

And Their Approving Parents: A Joyless Meditation

A while back I was asked, as a psychiatrist, to weigh in on the topic of Arab children who ask to become suicide bombers, and their approving parents. I took a pass. I wasn’t ready to go down that path, to set aside my shield of labels, all variations of “brainwashed,” “fanatic,” and “crazy,” and put down my cleaver that splits the me from them and the them from their humanity.

Then, I remembered. If psychiatrists can stand ready to help survivors of cults and kidnappings, and returning POWs, how is a child suicide-bomber applicant with approving parents any different? I set aside my shield and put down my cleaver and asked myself the following question: “Face-to-face with such a child and the approving parents, what would I say? Where might I begin?”

For this I began pondering the familiar experience of letting oneself get carried away by a destructive impulse, remembering and reflecting on those dares and double-dares of childhood. I reflected on our readiness to tear down goal-posts following a victory on the gridiron in our teens and our joining a march as young adults and remaining even after it morphed into a destructive riot. A part of us knew there was more at risk than property; there was our health, reputation, and career. But, at such moments these aren’t our priorities, are they? “I don’t know why I did that,” you hear yourself telling a parent, teacher, or judge. Think of actor Mel Gibson who said as much following his drunken anti-Semitic rant after a traffic stop, or those youthful accusers during Salem’s witch trials in the 1690s and their subsequent apologies. Think of Pinocchio. They all had one thing in common; they came to their senses. They woke up, or grew up, as it were, and felt and expressed remorse.

So, the question becomes: wherein does the state of being carried away by group-think become one’s permanent state of mind, one from which one never wakes up or grows up and comes to one’s senses? It’s as if, for some, there simply isn’t a self to wake up-a self-awareness, an awareness of self-with-agency. And never was. It’s as if for some children who’ve never had support for pondering and raising questions, only for doing and thinking as they were told, obedience has been their consistently reliable source for belonging, identity, appreciation, and love. What would it mean to such a child, now a youth, to be told, “Just be yourself”? And if that doesn’t carry meaning might the absence of affirmation of one’s individuality in early life account for that? Are we talking about a sense of Self that is not simply dark, it’s absent?

For us in the West, of course, submission to the will of a group is generally a conditional thing-temporary-whereas in the Arab world it can be unconditional and permanent. What we might call a deprivation they might consider an asset wherein hope for redemption, for a recovery of lost honor and dignity, if not in this life then in the next, is bona fide. Obviously, the mention of fulfillment and becoming whole can have different meanings. It’s not so surprising, then, that people who approve of and sponsor suicide bombings by children never seem to use the word “death” in their justifications, promotions, and celebrations, preferring instead words like being (eg, being a martyr, being in Paradise) and becoming (eg, becoming a Hero), highlighting what is gained, not lost.

We’re uncomfortably close, here, to a distinctly un-Western version of “Born Again,” which, creepy as it feels, sheds sobering light on our task. In both cases-theirs and ours-we are talking about religious people, determined to faithfully do God’s will by doing the right thing, unafraid to sacrifice to make the world a better place.

I’m reminded of the Bible story of Eve in the Garden of Eden who bit into that apple even though she’d been told she would die if she did. I don’t think she was thinking of dying back then, or even death. I don’t think she even knew what those words meant, nothing having ever died in the Garden. How could she know? So, like Eve, maybe for prospective child bombers and their parents it’s not death they have in mind but a state akin to transformation, of being “Born Again.”

There’s this story we tell of the psychiatrist becoming frustrated trying to talk his patient out of the delusional belief that he, the patient, is actually dead. “You’re alive!” the doctor finally begins shouting in abject frustration. “No. I’m dead!” the patient shouts back until, in desperation, the doctor grabs a letter-opener. “Do dead men bleed?” “No!” The psychiatrist stabs the patient’s arm and the patient, staring with disbelief at his bleeding arm, murmurs, “I was wrong. Dead men bleed.” We laugh, of course, never thinking to ponder what such a patient might have meant by “dead” or why his doctor never asked. Just because we don’t use words in the same way, doesn’t mean we’re not, in some sense, on the same page. Just because someone speaks of wanting to die, to suicide, doesn’t mean he or she is depressed, doesn’t rule out a motive of simply trying not to go mad, end pain, or not be a burden. How many people have, while psychotic, killed others, not from hate or anger as the media automatically assumes in their coverage, but from fear of harm and the urge to protect, to save themselves, or others. Or the world?

One can see where a would-be bomber and the parents, having made this decision, stand out among their peers in a new way, noticed and affirmed. One can see where this, for them, is a new experience, status, and identity that commands attention and respect. They have stepped forward to stand apart and are now special. Might their orchestrating and experiencing this new status represent an instinctual pull toward the completion of something that had been aborted years before, something that had never developed, that singular voice that no one would dare silence now? Might this be a manifestation of a wholeness with agency, long denied? Such a formulation would, of course, be a reach, but it’s not that hard to imagine these children and their parents trying, in this way, to realize something, complete and fulfill something. If not something in their lives, then something in the lives of their People or in the world of their Maker. Such behaviors, for child and parent both, might not be about anger, revenge, brainwashing, or madness. They may simply be about repair and redemption.

I can imagine myself now across the table from that child who asks to be a suicide bomber. His parents are with him. I am there as analyst, maybe designated healer. Where do I begin? I begin where they are, where both of us are. Healers trying to make the world a better place.

Psychiatrist on the Road: Encounters in Healing and Healthcare, 

an account of his Locum Tenens experience.

If psychiatrists can stand ready to help survivors of cults and kidnappings, and returning POWs, how is a child suicide-bomber applicant with approving parents any different?

Children Who Ask to Become Suicide Bombers

FROM THE NATIONAL NETWORK OF DEPRESSION CENTERS

Telepsychiatry has moved from an esoteric curiosity to mainstream practice. It has been challenged along the way at many turns. Some degree of scientific skepticism is required when considering any health care innovation. While the utility of telepsychiatry seemed obvious to many, it was always necessary to develop a robust literature in support of its effectiveness and for acceptance of this health care innovation and associated technology. That task was achieved long ago.

An outgrowth of the supporting evidence has been the creation and adoption of guidelines to assist clinicians in the implementation of telepsychiatry. The efforts at guidelines began shortly after the earliest attempts at instituting telemedicine practices. Historically, the 

 (APA) was a slow adopter of telepsychiatry. To its credit, over time it has moved from skepticism to gradual embrace, to acceptance and enthusiastic promoter of telepsychiatry.

Telepsychiatry has its origins in the 1950s. However, the more modern incarnation grew from Internet advances and the ubiquity of adequate bandwidth. As with any novel technology or practice, mainstream acceptance could only follow pilot projects and pioneering efforts. Protocols and processes were created from scratch for these initial programs. Those who are the first to put new tools into use do so without the benefit of established guidelines. However, it is only through such efforts that the data and evidence can be collected and the field refined to allow for the development of the standards that follow.

In this regard, telepsychiatry is no different from any other area of medicine where technical developments have moved from theory to established and routine practice. Activities, disciplines, and methods that are available to identify, implement, and monitor the available evidence in health care are called “

 Such guiding principles must hold up to the scrutiny of those who are active in the field. Those protocols developed during the early adoption of a new technology must withstand repeated challenges if they are to garner wide acceptance and mainstream implementation. The evolution of telepsychiatry has followed this process. Specific technical organizations formed and grew to support such innovation. These groups then give back to the field through the aggregation of data followed by thoughtful synthesis and promulgation of this material to others who are prepared to follow.

Current best practices for videoconferencing-based telemental health

With suitable fanfare, the most recent version of 

Best Practices in Videoconferencing-Based Telemental Health

 was adopted by both the APA and the American Telemedicine Association (ATA) in the spring of 2018. The foundational texts were updated, streamlined, and harmonized and culminated in this co-branded document. While the chair of the APA telepsychiatry committee is a psychiatrist by definition, it is not a given that a psychiatrist, or even a physician necessarily, would happen to hold either of the two key ATA offices. This fortuitous arrangement of office holders and the opportunity to synchronize between the two organizations greatly facilitated the creation of this document.

When the writing committee convened to begin work on the new co-branded document, they drew upon precursor works that dated back to 1998.

 On the APA side, it required the merging and updating of ATA works from 

A writing committee composed of 11 thought leaders from both organizations undertook an iterative writing process that produced the new document. Support staff from both organizations also contributed to the success of the final product. Once a working draft was completed, it was distributed to larger groups within the two organizations including the Telemental Health Special Interest Group (TMH SIG) of the ATA, the APA Committee on Telepsychiatry, the ATA Standards and Guidelines Committee, as well as both ATA and APA staff. Feedback from this extended review was incorporated into the final work, which has been received with widespread acceptance within the field.

The final product serves as an example of high level collaboration between large organizations working toward a common goal. The document became available online on the websites of both APA and ATA and was recently published in 

, the leading journal of the telemedicine field.

 The document itself stands as a succinct summation of accepted best practices for deploying telemedicine technology in the service of mental health care.

The process by which the document came into existence, was refined, and ultimately promulgated should also serve as an example. Other areas of the medical field where multiple groups are working in an area with intrinsic and overlapping interests in the success and growth of that initiative could benefit from emulating this process. Writings on technology topics are prone to having relatively short shelf-lives as the technologies themselves rapidly evolve. This concern was embraced by the writing group through a focus on outlining principles and practices that are less likely to be subject to obsolescence in the face of technological progress. Hopefully the stage has been set for future collaborations of this sort. When the time for an inevitable updating of the document is required, perhaps a similar representative group of professionals will come together for that task as well.

Dr Caudill is Professor, Director, Psychiatry Resident Training Program, and Director, Telemedicine and Information Technology Programs, Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY; Dr Shore is Chief Medical Officer, AccessCare (a company that provides telemental health services). Dr Caudill reports no conflicts of interest concerning the subject matter of this article); Dr Shore reports that he receives royalties from American Psychiatric Association Publishing, and he serves on the Board of Directors of APA.

, of which Drs Caudill and Shore are the co-chairs. NNDC’s goal is to foster collaborative research to advance scientific discovery and drive forward improved care for patients with depression and mood disorders. NNDC is an American-based initiative and is a content partner of 

What is “best practice” in health care? State of the art and perspectives in improving the effectiveness and efficiency of the European health care systems

Practice guidelines for videoconferencing-based telemental health: October 2009

Association. Practice Guidelines for Video-Based Online Mental Health Services

 Shore JH, Yellowlees P, Caudill R, et al. Best Practices in Videoconferencing-Based Telemental Health. 

Telepsychiatry has its origins in the 1950s and has moved from an esoteric curiosity to mainstream practice. However, it has been challenged along the way at many turns.

The History and Value of Guidelines for Best Practices of Telemental Health

Throughout my life I have found myself reflecting on the philosophical question of how my life would be, or in fact would I be here at all, if a single event in history had occurred differently. Impersonal events like the extinction of the dinosaurs or a larger accretion of stardust resulting in the Earth orbiting the sun at a greater distance, incompatible with life, are obvious major events. However, it is the smaller and more personal events that bring up strong emotions and relief when I reflect on these.

My mother died on July 14th at the age of 83. She died peacefully after years of progressing medical ailments. My father, my 4 siblings, and I were all with her, and she had said her goodbyes to her extended family and friends. She welcomed her passing with relief, ready to join her parents in the heaven that had been such an important part of her life. It was during the ensuing days, with the telling of all the stories and remembrances of my mother’s life, that I found myself reflecting on the unpredictable web of events and decisions that easily could have eliminated me from this story. For brevity, I will share three.

Although my grandmother’s due date was Christmas Day, my mother was born on Thanksgiving Day in 1935 during a blizzard in Salem, MA. When my grandmother went into labor that day, my grandfather called the doctor, who informed them it was likely “false” labor, and he was unable to go to their home due to the severe weather. This weather also served to trap them in their home, unable to go to the hospital. Later that day, in the family home, my great grandmother delivered my mother, who was then placed in a drawer next to the wood stove in the kitchen to keep her warm. She weighed 4.5 pounds and was healthy.

My mother’s family was devoutly Catholic, and after attending an all girl’s Catholic high school my mother wanted to become a nun. Wisely, my grandfather asked her to delay that commitment for a year, and to attend some type of post high school education. My mother joined her best friend in attending the Salem Hospital School of Nursing, where she discovered her passion for pediatrics, and she worked as a pediatric nurse until she retired. She married my father and gave birth to 5 children over 10 years.

In 1975, at the age of 39, my mother received a diagnosis of a rare cardiac anomaly that she was unknowingly born with. A fistula connected her coronary sinus with her left coronary artery, and it had slowly grown in diameter to the width of a pencil, shunting the oxygenated blood away from her heart muscle and back to her right atrium. During her 30s, as her heart enlarged, she became increasingly short of breath with minor activity; finally, a cardiologist made the correct diagnosis. The only treatment option was open heart surgery to close the fistula, which was very new medical technology at that time. In 1975 she became one of the first open heart surgery patients at the Massachusetts General Hospital in Boston.

These are but three of hundreds, likely hundreds of thousands of events and decisions that have had a direct impact on me in unknowable ways. And so, it is for each of us, reminding us of our responsibility to make each decision and choose each action wisely and thoughtfully, but simultaneously accepting the reality that an infinite web of events have led us to this life, and this moment.

Mom, thank you for your choices and actions, and may you rest in peace.

The author reminds us of our responsibility to make each decision and choose each action wisely and thoughtfully in life.

The Passing of a Matriarch

Boarding of psychiatric patients in medical emergency departments (EDs) for hours or even days is a serious issue plaguing hospitals across the country. Typically, the emergency physician has determined that the patient needs further psychiatric care. However, the sole option available is usually admission to an inpatient psychiatric facility.

Unfortunately, few regions have enough inpatient psychiatric beds to meet the needs of a system predicated on admitting the majority of ED patients, especially since, in the past decade, behavioral health patients have risen to become one in every eight cases in EDs in the US.

 As a result, psychiatric patients can end up confined indefinitely in small ED quarters with a sitter or security guard, or restrained to a gurney in a back hallway, while they await admission. Many of these boarded patients receive little or no psychiatric treatment beyond sedation. Thus, sadly, the most highly acute patients in a mental health system are often ironically the most underserved.

Fortunately, we now have an evidence-based solution that can fill this glaring gap in the psychiatric care continuum: hospital-based psychiatric EDs. These timely, compassionate, trauma-informed, and cost-effective programs have the potential to not only dramatically improve treatment options, but also save behavioral health systems millions of dollars annually by stabilizing patients in the emergency setting, and thus avoiding costly inpatient admissions.

Hospital-based psychiatric EDs are also known as Psychiatric Emergency Services (PESs), Comprehensive Psychiatric Emergency Programs (CPEPs), Clinical Decision Units (CDUs) or, more recently, EmPATH Units (Emergency Psychiatry Assessment, Treatment and Healing Units). Psychiatric EDs have been shown to stabilize over 75% of high-acuity psychiatric outpatients within 24 hours.

 These units provide far faster relief from distressing mental health symptoms than traditional treatment pathways while preserving inpatient psychiatric beds for patients who truly have no alternative.

This article, the first of a three-part series, describes how hospital-based psychiatric EDs differ from community-based crisis centers. Also explored is how these centers can serve as the missing link in comprehensive behavioral health systems while complementing both inpatient and community services. The second installment will highlight innovative psychiatric ED programs around the nation and their impressive outcomes and metrics. And in the final installment, the perplexing reimbursement issues facing psychiatric EDs will be discussed with strategies to overcome them suggested.

Differentiating hospital-based psychiatric EDs from community crisis centers

Community-based crisis centers have burgeoned in recent years and have been a valuable addition to the spectrum of behavioral health services. Typically basing their approach on a Wellness and Recovery model, they can help many people through difficult life events, stressful situations, and decompensations of chronic psychiatric illnesses. Also known as drop-in or walk-in services, crisis intervention or diversion, community subacute crisis stabilization units, and psychiatric urgent care, these welcoming facilities are typically located away from hospitals-often near public services and mental health clinics.

Community crisis centers are most commonly staffed by therapists and social workers trained to counsel individuals while providing a safe and supportive environment. Psychiatrists or psychiatric nurse practitioners may also be available, though their hours are usually limited.

Most community crisis center patients self-present or are escorted voluntarily to the clinic by case managers, mobile crisis personnel, or police officers. Each patient typically receives a thorough psychosocial assessment and referrals to follow-up care. Some clinics also provide overnight crisis stabilization services.

Yet while community-based programs provide many benefits, they are usually not equipped to care for patients with serious or dangerous psychiatric conditions. These centers commonly have a long list of exclusion criteria such as acute aggression, danger to self, involuntary status, or comorbid substance abuse disorders (

). Both current and prospective patients who display these criteria are typically directed to hospital EDs or transported there by law enforcement or emergency medical services; indeed, many centers have required treatment algorithms for high-acuity patients that clearly end in “send to hospital emergency department or call 911.”

It is worth noting that these types of patients who would be excluded from community crisis centers likely make up a large percentage of the high-acuity individuals who end up boarding in EDs awaiting inpatient care. So, while community crisis centers can do fantastic work, they might have a negligible effect on ED utilization involving patients with high-acuity psychiatric conditions. In fact, expecting these organizations to handle the most acute psychiatric patients would be like expecting a private doctor’s office to treat heart attacks and severe car accidents.

Through no fault of their own, some community crisis centers have become victims of unrealistic expectations. State and county behavioral health leaders might assume that by creating these centers they will dramatically reduce the number of psychiatric patients presenting to EDs-and therefore put a dent in ED boarding. This is not only unfair to the centers, it also sadly underestimates how serious, debilitating, life-threatening, and unpredictable the emergency symptoms of severe mental illness can be, and how these require an elevated level of care.

This is where hospital-based psychiatric EDs fit in. Because emergency psychiatry programs are designed to work with highly acute individuals, they can typically accept the lion’s share of patients who would be excluded from community crisis centers. But rather than board patients for admission as would traditional medical EDs, hospital-based psychiatric EDs quickly assess and initiate prompt treatment, with a goal of stabilization in the emergency setting, and discharge to home or other less-restrictive levels of care rather than inpatient admission. And indeed, across many different locations and care models-rural and urban, academic and municipal-psychiatric EDs have proved very effective. The great majority of psychiatric ED patients in programs around the country, typically 70% to 80% or even higher, successfully stabilize and return home or to outpatient dispositions in less than 24 hours.

Treating high-acuity patients in psychiatric EDs rather than boarding them in general EDs just makes sense. Psychiatric cases are the only class of patients seen in EDs for whom the default treatment plan has traditionally been inpatient admission. An ED would not, for example, hold a patient having an asthma attack for transfer to an “inpatient asthma bed”; instead, they would treat the patient’s breathing difficulties as soon as possible. Psychiatric emergency patients are also experiencing urgent distress and deserve that same rapid approach.

Initiating prompt emergency care is exactly what the psychiatric EDs do. This is also completely consistent with the federal Emergency Medical Treatment and Labor Act (EMTALA) governing hospitals that considers high-acuity psychiatric emergencies to be equivalent legally to medical emergencies, deserving the same immediate attempts to evaluate and stabilize. Meanwhile, patients who may benefit most from community crisis centers might be unlikely to require the high-acuity approach of the emergency psychiatry sites and would perhaps be reluctant to go to hospital EDs in the first place-so these programs can optimally work together in an almost completely complementary way, which would rarely be redundant.

One historic distinction has been the idea that hospitals use the medical model while community crisis centers are more wellness and recovery focused, but this does not have to be the case when a hospital-based psychiatric emergency program is part of the system. Many psychiatric EDs-particularly newer designs like EmPATH Units-blend the wellness and recovery model with the medical model, hoping to bring the best of both approaches, where appropriate, to the unique challenges of high-acuity patients. The result is a supportive, calming, and homelike environment where patients can also receive the specialized medical attention and intervention needed. There is thus potential for a seamless continuity of care philosophy connecting hospital-based psychiatric EDs and community crisis clinics.

It is clear that to provide every patient experiencing acute psychiatric symptoms with timely, individualized, and an appropriate level of care, and to minimize ED boarding, mental health systems should endeavor to support both community crisis centers and hospital-based psychiatric EDs.

Dr Zeller is Vice President for Acute Psychiatry with the physician partnership Vituity and Assistant Clinical Professor of Psychiatry, University of California, Riverside, CA. He is an Editorial Board Member of 

 Santillanes G, Lam CN, Axeen S, Menchine MD. 45 trends in emergency department mental health visits from 2009-2015. 

 Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. 

 National Council 2015 Crisis Services Survey. 

https://www.thenationalcouncil.org/wp-content/uploads/2015/04/CrisisServices_SurveyResults.pdf

This article, the first of a three-part series, describes how hospital-based psychiatric EDs differ from community-based crisis centers.

Hospital-Based Psychiatric Emergency Programs: The Missing Link for Mental Health Systems

This activity offers CE credits for:
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Caffeine requires no introduction as it is the most commonly consumed psychotropic drug in the world. It is primarily used for its predictable psychostimulant properties on the CNS. As with many drugs found in nature, it naturally occurs in select plant species located in Africa, East Asia, and South America. For these plants, it serves as an insecticide and a fungicide. It is commonly found in the leaves, seeds, and/or nuts of coffee, tea, and cocoa plants.

Caffeine is a member of the molecular class methylated xanthines, which also includes theophylline, theobromine, and paraxanthine. All four molecules are remarkably similar in structure, and the non-caffeine members vary only in the placement of their two methyl groups (CH3). Caffeine uniquely has a third methyl group and is metabolized by the liver to varying percentages of the other three. All have psychostimulant properties but vary in other physiological effects. Theophylline also functions as a bronchodilator, and, not surprisingly, is used in the treatment of asthma and chronic obstructive pulmonary disease. Theobromine has significant diuretic properties in addition to its weak psychostimulant effects. Paraxanthine does not exist naturally in any plants but is the most common metabolite of caffeine in humans.

The coffee bean, which seems to have originated in Yemen, has only caffeine. It was first described around 1450, at which time Sufi monks used the coffee bean to make a beverage to help with wakefulness while praying in their monasteries in Yemen.

 Tea leaves contain primarily caffeine, but also have varying degrees of theophylline and theobromine. The use of tea as a beverage is described as far back as 3000 BCE, and tea leaves are found throughout East Asia.

 The cocoa bean contains primarily theobromine, with some caffeine and virtually no theophylline. Cocoa bean residue has been found in a Mayan pot dating back to 600 BCE.

Historically, it has been challenging to elucidate the mechanism of action of caffeine as a CNS psychostimulant. Previous competing theories included: increase in calcium release; inhibition of the enzyme phosphodiesterase that results in an increase in the secondary messenger cAMP; and interaction with adenosine receptors. This third theory is now believed to be the primary mechanism by which caffeine acts as a psychostimulant.

Caffeine, which is similar in structure to adenosine, is a competitive antagonist of adenosine A1 and A2A receptors (A1R and A2AR). The psychostimulant effects of caffeine can be neurobiologically dissociated into psychomotor activation and increased arousal. Both pharmacological properties are responsible for the wide use of caffeine. The increased arousal is related to the caffeine-mediated counteraction of the effect of adenosine on homeostatic sleep. Caffeine counteracts the adenosine-mediated sleepiness induced by prolonged wakefulness, mostly by acting on A1R that control the activity of ascending arousal systems. On the other hand, caffeine produces psychomotor activation by acting preferentially on A2AR, by indirectly controlling striatal dopaminergic transmission.

After drinking a beverage containing caffeine, it takes from 30 minutes to 2 hours to reach its maximum serum concentration on average. Because of its property of solubility in both lipids and water, it is rapidly distributed evenly in all tissues throughout the body. It readily crosses the blood-brain barrier, allowing rapid access to receptors in the brain.

There are a number of factors that can affect the metabolism of caffeine in humans, and hence its pharmacokinetics. The average half-life of caffeine in humans is 2 to 6 hours. Caffeine is metabolized by the liver in first pass metabolism through the cytochrome P450 1A2 enzyme (CYP450 1A2). In addition to being a substrate for CYP450 1A2, caffeine is also a moderate inhibitor of this enzyme.

These properties have significant consequences for how the metabolism of caffeine is affected by some drugs, and how other drug metabolisms are affected by caffeine. The most common drug-drug interaction, which can have a clinical effect on how much caffeine is required to achieve a psychostimulant effect, is related to smoke. It is well established that smoke from any source (nicotine cigarettes or cigars, cannabis cigarettes, lengthy and prolonged exposure to smoke from a wood fire) induces the liver’s CYP450 1A2 enzyme-gradually increasing the activity of this enzyme by continuous smoke exposure over 2 weeks. This induction results in increased metabolism of caffeine by the CYP450 1A2 enzyme, requiring more caffeine to attain the same blood level as would be required in a non-smoker.

Estradiol inhibits the metabolism of caffeine; hence taking estradiol on a regular basis requires less caffeine to achieve the same level as being off estradiol. During pregnancy-a high estrogen state-the half-life of caffeine can be increased up to 15 hours in the third trimester. The SSRI fluvoxamine, FDA approved to treat obsessive compulsive disorder, is a potent inhibitor of CYP450 1A2 and has been shown to increase caffeine’s half-life 10-fold.

Moreover, caffeine can elevate blood levels of some medications that can have significant clinical effects. Through its activity as a moderate inhibitor at the CYP450 1A2 enzyme, caffeine can increase the serum levels of clozapine and warfarin. Patients who are taking clozapine can be challenging to maintain at a steady serum level, as smoking cigarettes will decrease clozapine levels and drinking caffeinated beverages will increase clozapine levels.

Adenosine-dependent modulation of striatal dopamine and glutamate neurotransmission

Psychomotor activation is a major pharmacological effect of psychostimulants and classically implies a behavioral activation in response to specific stimuli, more specifically, to reward-related stimuli (rewards, conditioned rewards, or discriminative stimuli that signal the proximity of rewards). Psychostimulants also have reinforcing properties-the psychostimulant, itself, acts as a “reward” (ie, rewarding stimulus or reinforcer), implying that it elicits approach and work to obtain it.

These properties of psychostimulants are similar to those of dopamine in the brain and, particularly, in the striatum, the brain area with the highest dopamine innervation and the highest density of dopamine receptors. Thus, activation of the central dopamine system is involved with increasing responsiveness to reward-related stimuli-with orienting and approaching responses to those stimuli-thus reward-oriented behavior. Concomitantly, dopamine is directly involved with the learning (“stamping-in”) of stimulus-reward and reward-response associations that follows the receipt of reward.

Stimulus-reward associations lead some stimuli to acquire discriminative properties that signal the proximity of the reward or even to acquire rewarding properties (ie, conditioned rewarding stimuli), which become themselves behavioral attractors. The stamping-in of reward-response associations promotes positive reinforcement, the learning of the optimal sequential response-the action skill-that leads to the reward.

Dopamine cells increase their activity by the cues that predict the occurrence of the reward (discriminative/conditioned reward stimuli) and when the reward is better than expected (positive reward prediction error), in which case there is a phasic increase in striatal dopamine. This dopamine increase promotes activation of excitatory dopamine D

R), which have low and high affinity for dopamine, respectively. D

R are separately localized in the striatal cells that respectively constitute the “Go” (excitatory) and “No Go” (inhibitory) striatal efferent neuronal outputs.

The respective activation and inhibition promote the elicitation and learning of positively reinforced behaviors (approach behaviors). But dopamine cells also receive signals related to aversive stimuli and increase their activity with cues that predict the successful avoidance of an aversive stimulus. Consequently, there is elicitation and learning of negatively reinforced behaviors.

On the other hand, aversive stimuli (or cues that predict a non-avoidable aversive stimulus) produce inhibition of dopamine cell activity, which leads to the loss of a tonic activation of the high affinity D

R by endogenous dopamine. The consequent increase in the activity (by release of the D

R-mediated neuronal inhibition) of the “No Go” neuronal output, which is represented by the striatopallidal neurons, leads to freezing/withdrawal/escape behaviors.

Classic psychostimulants, such as cocaine, methylphenidate, and amphetamine, activate the dopamine system by increasing the concentration of extracellular dopamine. In contrast, caffeine potentiates the effects of dopamine by counteracting adenosine neurotransmission. Blockade of A1R and A2AR in the striatum by caffeine releases the brake that endogenous adenosine exerts on dopamine activation, which is related to the ability of both adenosine receptors to establish molecular interactions and inhibitory modulations of dopamine receptors. Postsynaptic A2AR play the most significant role in the modulation of striatal dopamine neurotransmission.

R, the striatopallidal neuron expresses the highest density of A2AR in the brain (

). Experimental data indicate that striatal A2AR constitute the main target responsible for the psychomotor activating and rewarding effects of caffeine (for recent review, see FerrÃ©

). Significantly, the predominant populations of both A2AR and D

R in the striatopallidal neuron establish strong functional and intermolecular interactions, forming A2AR-D

R heteromers (a receptor complex of, at least, two different receptors). With a significant lower density, A2AR are also localized presynaptically in corticostriatal glutamate terminals, where they form heteromers with A1R.

Recent studies have provided details about the molecular structure and functional properties of A2AR-D

R and A1-A2A receptor heteromers. They constitute heterotetramers (with homodimers of A2AR and D

R or A2AR and A1R) that form part of large pre-coupled signaling complexes that include their cognate G proteins and the effector adenylyl cyclase (

R heterotetramer acts as an integrative molecular device that allows reciprocal antagonistic interactions between adenosine and dopamine to facilitate a switch in the A2AR-mediated activation versus D

R-mediated inhibition of the striatopallidal neuron. In fact, A2AR activation is responsible for the increase in the activity of the striatopallidal neuron and the consequent freezing/withdrawal/escape behaviors induced by release of the D

R-mediated neuronal inhibition upon exposure to punishment-related stimuli. Caffeine or selective A2AR antagonists, on the other hand, block these effects and potentiate the effects of endogenous dopamine on D

R-mediated neuronal inhibition, promoting an apparent psychomotor activation as a result of inhibition of freezing/withdrawal/escape from punishment-related stimuli.

The striatal A1R-A2AR receptor heteromer constitutes a molecular device to fine tune glutamate transmission. Low concentrations of adenosine activate A1R, which inhibits glutamate release, while higher concentrations also activate A2AR, which causes the opposite effect. Since there is a predominant tonic activation of presynaptic A1 versus A2AR, caffeine acts mostly as a presynaptic A1R antagonist and promotes a facilitation of striatal glutamate transmission, which locally promotes dopamine release from striatal dopamine terminals, therefore adding to the postsynaptic potentiation of dopamine transmission mediated by the A2AR-D

R heteromer in the striatopallidal neuron.

Adenosine-dependent modulation of glutamate neurotransmission in the amygdala

The striatum is not the only localization of A1R and A2AR in the brain; adenosine also controls glutamate neurotransmission in other brain areas, such as the amygdala, by segregated presynaptic A1R and postsynaptic A2AR (expressed with significantly lower levels than in the striatum).

 The amygdala is the critical substrate of Pavlovian aversive conditioning, (ie, fear conditioning). The conditioned and unconditioned aversive stimuli converge in the lateral nucleus, where a variety of cellular events transform a neutral stimulus into an aversive conditioned stimulus.

The central nucleus of the amygdala is the major amygdalar output. For instance, its projections to the periaqueductal gray are involved in conditioned stimulus-induced freezing. Information from the lateral to the central nuclei is conveyed by the basal nucleus and the intercalated cell masses. The adenosine control of glutamate transmission onto the pyramidal neurons of the basal nucleus of the amygdala seems particularly critical. The A1R-mediated inhibition or an A2AR-mediated activation of the pyramidal cells of the basal nucleus leads to a respective decrease or increase in fear conditioning.

The opposite effects of A1R and A2AR blockade have been documented experimentally, with A1R antagonists facilitating, while A2AR antagonists decrease fear conditioning.

 Therefore, adenosine-mediated modulation of glutamate transmission in the amygdala represents a potential mechanism for the documented effects of caffeine on anxiety.

Anxiety disorders are common in psychiatry, and anxiety is a common symptom in many other psychiatric disorders. It is generally known that low doses of caffeine can be anxiolytic and high doses can be anxiogenic, particularly in susceptible individuals. Several studies indicate that a common block of polymorphisms of the A2AR gene (grouped by linkage disequilibrium) that is associated with an increased expression of A2AR in the brain, predisposes to panic attacks and to the anxiogenic effects of caffeine.

 Based on the role of amygdalar A1R and A2AR on fear conditioning, A1R blockade, and not A2AR blockade, should lead to anxiogenic effects, making it difficult to explain the role of A2AR gene polymorphisms in anxiety and caffeine-induced anxiety. But the involvement of A2AR localized in the most posterior and medial part of the ventral striatum, with its putative role in fear extinction-the suppression of fear (more appropriately threat) conditioning-provides a possible way out of this conundrum.

Apart from the dopamine neurons that respond with a decrease in their activity upon presentation of an aversive and punishment-related stimulus, a specific population of dopamine cells increases its activity. In rodents, this neuronal subpopulation seems to be mostly localized in the most medial and posterior part of the ventral tegmental area (VTA), which specifically projects to the most posterior-medial part of the ventral striatum, the posterior-medial shell of the nucleus accumbens (NAc).

 This area of the striatum is mostly innervated by the rodent infralimbic cortex, equivalent to the rostral anterior cingulate cortex (ACC) in humans.

The infralimbic cortex innervates the interconnected posterior-medial portions of the VTA and shell of the NAc, the amygdala, and the insular cortex, and this circuit plays a key role in fear extinction. Specifically, the amygdalar input from the infralimbic cortex corresponds to the intercalated masses. These correspond to GABAergic inhibitory neurons also innervated by the pyramidal neurons of the basal nucleus and their activation leads to active inhibition of fear conditioned responses, to fear extinction. According to LeDoux and colleagues,

 active avoidance learning, with the elicitation of a behavioral response that avoids the interaction with the aversive stimulus, requires the suppression of fear conditioning. This system provides a significant additional mechanism by which dopamine promotes negative reinforcement during the establishment of an avoidance behavior-the switch “from fear to safety.”

Although still speculative, the anxiolytic effects of low doses of caffeine could be mostly mediated by blockade of striatal postsynaptic A2AR (in the A2AR-D

R heteromers) and presynaptic A1R (in the A1R-A2R heteromers) in the posterior-medial shell of the NAc, which should be expected to potentiate fear extinction. With higher doses of caffeine or with an increased expression of A2AR, as in the presence of anxiety susceptibility A2AR gene polymorphisms, striatal presynaptic A2AR blockade (in the A1R-A2AR heterodimer) would promote anxiety.

Caffeine is a naturally occurring psychotropic drug that has been used for its psychostimulant effects by humans for thousands of years. It is legal and requires no regulation, ubiquitous in most cultures, and used by all age groups. Although found naturally in coffee beans, tea leaves, and cocoa beans, it is added to many beverages that are consumed daily for its psychostimulant effects.

Caffeine is also used in a variety of over-the-counter medications to treat various symptoms, ranging from headaches to somnolence. Furthermore, caffeine has a wide array of other physiological effects that we continue to discover and characterize. There is now a solid body of research that supports caffeine’s mechanism of action as a psychostimulant resulting from it being a non-competitive antagonist on adenosine receptors, in part through their ability to interact with dopamine receptors.

However, much work remains to be done, particularly in relation to the psychiatric implications. Clinical studies are needed that specifically evaluate the role of caffeine and A2AR antagonists in persons with anxiety. In order to establish the therapeutic versus anxiogenic doses of caffeine, studies should control for the role of anxiety susceptibility of A2AR gene polymorphisms, as well as polymorphisms of the gene for CYP450 1A2, which determine significant individual pharmacokinetic differences of caffeine.

However, this would still provide an incomplete picture because of the large variety of exogenous and endogenous factors, such as age, sex, hormonal status, diet, smoking, and exposure to drugs that influence caffeine intake, absorption, metabolism and pharmacological effects. An additional complication is the recent discovery of the psychomotor effect of paraxanthine, the main metabolite of caffeine in humans, which is related to its additional specific ability to inhibit a cGMP-preferring phosphodiesterase.

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Dr FerrÃ© is Senior Scientist and Chief of the Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Department of Health and Human Services, Baltimore, MD.

The World of Caffeine: The Science and Culture of the World’s Most Popular Drug

 Nehlig A. Interindividual differences in caffeine metabolism and factors driving caffeine consumption. 

Concise Guide to Drug Interaction Principles for Medical Practice: Cytochrome P450s, IGTs, P-Glycoproteins

, 2nd ed. Washington, DC; American Psychiatric Publishing; 2003.

This CME article discusses the pharmacokinetics of caffeine and its implications on anxiety.

Psychiatric Times Vol 36, Issue 8

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The Passing of a Matriarch

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Caffeine: Neurobiological and Psychiatric Implications

Making Your Practice Work for You

Polypharmacy: A Challenge for Community Psychiatrists

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All the World’s Notes

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