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 Tales of the Clinic, The Art of Psychiatry, 

we visit a case of a young woman struggling with opioid use disorder while pregnant. This woman was lucky enough to have access to a multidisciplinary treatment clinic, including psychiatry and maternal-fetal-medicine, and to have family support. Pregnancy is often a time of renewed interest in being off drugs and trying to build a healthy mom-baby dyad, but also a time of struggle, given hormonal changes and lack of specialized treatment guidelines for this population. Cooccurring issues such as mental illness, trauma history, and negative social determinants of health often make treatment extremely challenging.

“Ms Landry” is a 25-year-old female with generalized anxiety disorder, reported history of bipolar disorder, 

 (OUD), methamphetamine use disorder, cocaine use disorder, benzodiazepine use disorder, and tobacco use disorder. She presented in September 2020 to the emergency department (ED) for management of opioid withdrawal, as she found out several weeks prior that she was 

. She wanted to be off drugs for her baby. Due to irregular menses, she was unable to state how far along she was in the pregnancy. She reported using intravenous heroin over the last 4 to 5 years, with her last use 2 days ago. She stated that she has used 1.5g per day for the past year-and-a-half, since she has been homeless.

At the time of presentation, she endorsed worsening symptoms of withdrawal, including rhinorrhea, diarrhea, nausea/vomiting, abdominal pain, flushing, and chills. After workup and imaging, she was estimated to be 8 weeks pregnant. Consult-liaison psychiatry was consulted by OB/GYN for medication-assisted treatment initiation. Ms Landry reported that she had been tried in the past on both methadone and 

. She described her primary motivation for seeking treatment as her pregnancy and the opportunity to be a mother. She explained that it is her responsibility to ensure the physical well-being of her baby and agreed to start suboxone 4mg BID (buprenorphine 4mg/naloxone 1mg).

At time of treatment initiation, Ms Landry was living at multi-site residential and outpatient substance use treatment center, which also provides care for pregnant and parenting women, along with their children. Following initiation of suboxone and resolution of withdrawal symptoms, they discussed a plan for discharge to her mother or return to the facility. Ms Landry was inpatient for a total of 4 days. On the evening of her last day, she approached the obstetrician, requesting to leave the hospital. She described frustration that her boyfriend was not able to visit with her during nonvisiting hours. After brief discussion, she agreed to stay and follow the agreed-upon treatment plan. Several hours later, she left her room with her boyfriend and did not return. Attempts to contact her were unsuccessful.

Ms Landry started drinking with her father when she was 13 years old. She explained that it was used as a “bonding activity” and something they could do “behind mom’s back.” Her father also introduced her to 

. In later years, she was estranged from him due to other mental health issues (reported 

 and suicidality) and threats of physical violence made against her mother. Her parents later divorced, and her father died from complications related to 

. Ms Landry described her mother as a consistent source of support, and she later lived with her mother, following delivery. She also has a younger brother and reported no additional substance use disorder (SUD) in her family.

Following a sexual assault between the ages of 15 and 16 years old, she began to experiment with 

. At 18 years old, she moved out of her parents’ home and into the home of friend who used methamphetamine. Shortly after, she began using methamphetamine as well, both intravenously and via smoking. She described enjoying the energy it provided and how it “unbridled” her creativity. After being caught intoxicated at school around 19 years old, she was referred to and seen by a psychiatrist. She was given the diagnosis of 

, due to “erratic behavior,” although she continued actively using substances at that time. She says she was tried on both Vraylar and Latuda, with good effect. She also described multiple suicide attempts (SAs) around this time, including cutting and intentional overdosing on substances. She denied additional SAs following this period.

Several years later, Ms Landry met the father of her baby, who she continued to have an on/off relationship with over several years, leading to the pregnancy. At times, she reported the relationship as physically abusive. She stated that he introduced her to IV heroin, which was her substance of choice, when she initially presented to the ED. She has been to inpatient substance use rehabilitation programs several times and was able to maintain sobriety for 2- to 3-month periods. However, after programs concluded, she relapsed almost immediately each time she left. Her substance use has resulted in multiple arrests and DWIs.

Ms Landry had difficulties maintaining employment due to ongoing 

. After finishing high school, she was able to complete 2 years of college. She previously worked at one of the local airports, and also had jobs as a waitress and as a dancer.

From the initial presentation through multiple clinic follow-ups, a similar pattern emerged where Ms Landry would skip follow-up for both obstetrics care and psychiatry appointments, or where she would present to the hospital with symptoms of withdrawal and leave shortly after against medical advice. During this time, she lived between her mother’s home, hotels, and the local SUD treatment facility, with intermittent periods of 

. To pay for hotels, she would steal and sell objects.

She was forthcoming regarding her continued substance use and difficulty managing cravings on suboxone.Initially she reported she was relapsing on IV heroin, but later into her pregnancy, various collected UDSs were consistent with fentanyl, cocaine, and 

. During her initial presentations, she expressed interest in resuming methadone, but due to the daily dosing, was concerned about having regular transportation to the clinic. Toward the latter portion of her pregnancy, dosage of suboxone was titrated to 16mg. After delivery, transition to methadone was discussed, given inability to adhere to buprenorphine requirements including drug screens and clinic visits.

In addition to difficulties with transportation and housing, Ms Landry frequently did not have consistent access to a phone, adding another barrier to treatment. Her mother would be unaware of her whereabouts and unable to get into contact with her. When members of the team were able to contact her, she indicated that the baby’s father was present, and it was suspected that he encouraged guardedness during these conversations.

By the end of the pregnancy, Ms Landry stated she had ended her 5-year relationship with the father of the baby, due to continued substance use and physical abuse. She delivered her baby in early March 2021 at roughly 35 weeks. She presented via EMS to the ED for preterm premature rupture of membranes, and following delivery, her baby was transferred to the neonatal intensive care unit for prematurity. Child Protective Services became involved after the baby tested positive for cocaine. She again shared her intention to return to the local SUD facility. Shortly after, she left the facility against the advice of the treatment team. Following the baby’s discharge from the hospital, Ms Landry took the baby home. It was reported that she was sober for a total of 9 days throughout the remainder of her pregnancy.

Over the next 3 months, Ms Landry missed several appointments in the obstetrics and psychiatry clinics. On a few occasions, she would call the clinic following missed appointments to reschedule or reengage in SUD treatment, but then failed to present to clinic. The last documented encounter in her chart was when she presented to the ED, endorsing worsening withdrawal symptoms from recent IV 

. When she was called from the waiting room for further examination, staff were unable to locate her.

Throughout the United States, there has been a sharp up-tick in deaths involving synthetic opioids over the last decade. This is largely thought to be due to the rapid proliferation of illicitly manufactured 

 and fentanyl analogs (eg, acetylfentanyl, carfentanil), which are highly addictive and very potent.

 These substances are sold as a standalone product (ie, tablet or powder), as an additive to increase the potency of heroin at little cost, or as a substitute ingredient for more expensive sedative-hypnotic and opioid drugs, such as alprazolam, oxycodone, and hydrocodone.

 death rate in the United States was 14.98 per 100,000, with a median of 13.88 deaths per 100,000. The highest rate of opioid overdose-related death occurred in West Virginia (40.03 per 100,000), at roughly ~169% higher than the national average. In contrast, the lowest mortality rates were found in Texas (4.93 per 100,00), at approximately 3 times lower than the national average.

 However, results of a recent study at the University of Texas at San Antonio showed that although Texas has consistently had rates of mortality significantly lower than the national average, opioid-related deaths are on the rise. The study revealed that between 1999 and 2019, opioid-related deaths among persons aged 15 to 64 increased over 402% (from 3.8 per 100,000 in 1999 to 8.2 per 100,000 in 2019).3 Women accounted for 32.9% of those reported deaths.

Between 1992 and 2012, the rate of substance use treatment admissions among pregnant women with OUD increased from 2% to 28%.

 Similar to Ms Landry, demographic characteristics reflected a predominance of younger, unmarried, white non-Hispanic women; criminal justice referrals; and those with 

 In 2018, recognizing increasing incidence of mothers with OUD, the Substance Abuse and Mental Health Services Administration (SAMHSA) responded to the unique needs of women by outlining specific clinical guidance for 

The guides highlighted the complex needs of a women-centered approach to OUD treatment. These needs included the importance of adjusting the dose of MAT to account for the increased metabolic demands during pregnancy, breastfeeding, and breastmilk to decrease neonatal abstinence syndrome (NAS) severity among opioid-exposed infants; the provision of family-planning services that include highly effective contraceptive options to decrease high rates of unintended pregnancy; and engagement with obstetric, social services, and behavioral health providers during pregnancy and after delivery.

 Evaluation of 13,000 substance abuse treatment facilities across the United States found that only 40% offered women-centered OUD, listed in the aforementioned recommendations by SAMHSA.

In 2019, the Texas Health and Human Services Commission (HHS) was awarded $750,000 in federal funding to help increase access to treatment for pregnant and postpartum women with OUDs and enrolled in Medicaid.

 Goals for the initiative include establishing a multidisciplinary clinic designed to 

, reduce barriers to prenatal care, and improve the quality of maternal care for women with SUDs. Texas was 1 of 10 states chosen to implement this model of care, with aims closely related to the clinical guidelines by SAMHSA.

Ms Landry was able to utilize similar multidisciplinary services during her treatment course. However, as seen in her case, higher rates of intimate partner violence and sexual abuse, and cooccurring psychiatric disorders among women with OUD adversely affect levels of engagement and retention.

 Studies present mixed rates of continuation into the postpartum period, with some showing high rates of continued engagement into the postpartum period and others with rates of relapse as high as 56% at 6 months postpartum.

 Other factors in Ms Landry’s case—such as significant trauma history, history of substance use in her family, and misdiagnosis of psychiatric disorder leading to delays in care—add to the complexity of her presentation. These factors are not unique to her case, and further research should be done to develop additional modalities in treating pregnant and postpartum women with OUD.

is a PGY3 psychiatry resident at Baylor College of Medicine, in Houston, TX. She is currently on the Women’s Mental Health track and has additional clinical interest in addiction psychiatry, in which she plans to complete fellowship. 

is assistant professor at the Menninger Department of Psychiatry, Baylor College of Medicine. He specializes in addiction and women’s health/reproductive psychiatry, and serves as the primary psychiatrist on the maternal perinatal addiction treatment program.

Continued increases in overdose deaths related to synthetic opioids: implications for clinical practice. 

2. Lyle Cooper R, Thompson J, Edgerton R, et al. 

Modeling dynamics of fatal opioid overdose by state and across time. 

The burden of opioid-related mortality in Texas, 1999 to 2019. 

Recent trends in treatment admissions for prescription opioid abuse during pregnancy. 

Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants

. Substance Abuse and Mental Health Services Administration; 2018.

The pregnancy recovery center: a women-centered treatment program for pregnant and postpartum women with opioid use disorder. 

7. Phillips C. Texas awarded funding to help pregnant and postpartum women affected by opioid use disorders in Houston. Texas Health and Human Services Commission. December 20, 2019. Accessed February 28, 2022. 

https://www.hhs.texas.gov/sites/default/files/documents/mom-press-release.pdf

Opioid use disorder in pregnancy: health policy and practice in the midst of an epidemic. 

Substance use disorder may prove to be a significant issue for some mothers. 

“I Want to Do This for My Baby”: The Woes of Pregnancy and Addiction 

 is a leading cause of suffering and disability worldwide, affecting about 1% of the global population, community services for those with chronic schizophrenic illness are lacking in many areas. As a result, the emergency department (ED) often becomes a primary location for care of this severe mental disorder.

With our combined experience as an emergency medicine physician with interest in the management of acute psychiatric presentations (Furiato) and a psychotherapist with interest in the psychotherapy of schizophrenia (Ruffalo), we believe a psychologically (and psychodynamically) informed guide to the management of schizophrenia in the ED that incorporates relevant research from pharmacotherapy, psychology, and 

 can be very useful in the acute care of these patients.

Attempts to distinguish schizophrenia from the psychotic symptoms that occur in other mental and medical disorders date at least to Kraepelin’s pioneering work in the late 1800s. Another German psychiatrist, Kurt Schneider, proposed the “first-rank symptoms” of schizophrenia in 1939, and his theory held widespread popularity throughout the 20th century (

). A recent Cochrane review of Schneider’s first-rank symptoms (FRS) concluded that FRS correctly identifies individuals with schizophrenia 75% to 95% of the time.

 While reliance on FRS alone may not be sufficient to diagnose schizophrenia,

 recognition of FRS can aid ED physicians and mental health workers in the triage and care of patients presenting with psychotic disturbance.

Patients presenting to EDs may be well-known to ED staff; the course of schizophrenia is generally chronic and, in many geographic regions of the United States, comprehensive mental health systems are sorely lacking. In cases wherein the patient is a poor historian, or past records are otherwise unable to be obtained, reliance on clinical skill, such as knowledge of FRS, is necessary to ascertain the diagnosis of 

In certain instances, such as a clinical suspicion of new-onset schizophrenia or abnormal neurologic exam findings, use of brain imaging may be necessary to rule out organic disease of the nervous system. While a comprehensive review of brain imaging in psychosis is outside of the scope of this paper, Coentre et al

 note that neuroimaging is particularly useful in first-episode psychosis when patients are elderly, have neurological symptoms, or have an atypical clinical picture.

In the ED setting, the first and most important consideration upon presentation of the acutely agitated patient with psychosis or schizophrenia is the level of risk of harm they pose to themselves and staff.

 The resulting answer will help determine the route and type of medication for the specific patient. Speed of onset can dictate the route of administration, as those who are violent will need more rapid calming. These therapies should be used with verbal de-escalation techniques or directly after such attempts have failed.

Benzodiazepines, which are pharmacologically active on the gamma-aminobutyric acid (GABA) receptors, act on the central nervous system and are among the most common medications used for calming and sedation in the ED.

 The largest concentrations exist in the thalamus, cortex, and cerebellum. There are many different subclasses of GABA receptors, including the main α- and β- subunits. The biochemical neurotransmitter effects include reversable binding of the excitatory neuroreceptors and neuronal firing. The primary clinical effects are anxiolysis, 

 are also commonly used as the first-line agent of emergency treatment of seizure disorders and epilepsy.

 Potential adverse events include respiratory depression, hypoxia, hypotension, and paradoxical excitation reaction in those with organic brain disease. Depending on the lipid solubility of the agent and route of metabolism with patient comorbidities, half-lives vary widely (

Patients who are successfully verbally calmed and de-escalated can be considered for therapy with oral management with benzodiazepines alone or in combination with antipsychotics. Intramuscular medications combined with antipsychotics, often with the help of physical restraints, are used for those patients who cannot be de-escalated and pose a risk of injury to themselves and staff.

The 2 main categories of antipsychotics in the emergency setting are first-generation (typical) and second-generation (atypical) agents. The class distinctions are mostly important because of the associated adverse effects.

 First-generation antipsychotics were developed for the treatment of schizophrenia; they act on the multiple dopaminergic receptor, anticholinergic, and histamine pathways. Each drug has its own mechanism of action and level of antagonism of those pathways.

The hallmark first-generation drug is haloperidol, commonly used in the ED. It has been used with great success in treating the positive symptoms of schizophrenia. One of its main limitations, and ultimately a reason that prompted the development of the second-generation drug class, consists of extrapyramidal symptoms such as tremor, slurred speech, akathisia, dystonia, and 

The second-generation class of medications further treats the negative symptoms of schizophrenia and improves upon the adverse event profile of the first-generation group.

 Olanzapine and ziprasidone are common second-generation antipsychotics used in the ED. Significant adverse event of the second-generation drugs include sedation, hypotension, 

Many of the antipsychotics can be administered by mouth to those who are receptive to such and calm enough for safe administration. Antipsychotics can also be administered by intramuscular and intravenous injection for those who are severely agitated.

 Careful observation of the patient’s respiratory status by cardiac monitoring and continuous pulse oximetry must be done after administration, as adverse event can also include respiratory depression and hypoxia. The regular combination of benzodiazepines and antipsychotics can compound this risk. In addition, many of the antipsychotics can have adverse cardiac electrophysiologic effects, including prolonged QT intervals and the development of ventricular tachycardic arrythmias, necessitating electrocardiogram screening once the patient is chemically calmed.

 and antipsychotics used in the ED include lorazepam plus haloperidol or ziprasidone; and midazolam plus haloperidol or ziprasidone. The addition of the antihistamine diphenhydramine is also sometimes added to the aforementioned 2-drug cocktail for patients who are extremely violent. This practice is falling out of favor as seen in a recent retrospective cohort study.

 has also been examined for the acute management of the violently agitated patient.

 Ketamine is a dissociative agent that works at the N-methyl-D-aspartate (NMDA) receptor, which is thought to play a partial role in the development in schizophrenia. Ketamine, when given intramuscularly, can produce more rapid de-escalation and sedation vs the more traditional method of benzodiazepines plus an antipsychotic.

 The drawback to the use of ketamine is the theoretical possibility of exaggerating schizophrenic episodes due to activity on the NMDA receptors. There does not appear to be an increased need for inpatient psychiatric admission or ED psychiatric evaluation vs the traditional therapy.

 More research is needed to further assess the use of ketamine in the acute agitated schizophrenic patient.

Schizophrenia is a complex, multidimensional problem that requires appreciation of both biomedical and psychosocial aspects of disease management. This is true not only in the psychiatric treatment setting but also in the ED, since patients with schizophrenia may exhibit the most severe symptoms in the acute care setting.

Of greatest importance, perhaps, is the recognition that the patient’s heightened state of 

 has contributed to their current psychotic disintegration.

 The patient with schizophrenia often feels alone and afraid, isolated, and without any sense of basic trust or security. The threat of interpersonal contact is too much for them to bear, so they escape even deeper into their psychotic world. Care must be taken to avoid any unnecessary situations in which the patient’s anxiety is increased, as this will only worsen the psychotic symptoms.

Any attempt to challenge or question the validity of delusional themes will result in utter failure, so the ED clinician must avoid these types of confrontations. At the same time, the clinician should not tacitly agree with the patient’s deluded ideas but instead explain empathically that there are reasons they are experiencing things differently. Again, the clinician must do everything they can to foster an environment in which some semblance of trust can be established. For the patient who is mute or otherwise difficult to engage in an interview, speaking about neutral subjects, such as the weather or sports, may help alleviate anxiety and open up the patient to answering some basic questions.

While it is, of course, necessary to gather some information from the patient to establish a history and determine appropriate disposition, the patient with schizophrenia may experience too many questions as an imposition. As Silvano Arieti, MD, noted, “The request for information is often interpreted by the patient as ‘an attempt to take something from him.’”

 The aim of the ED interview should be less the collection of detailed information and more of a process of relating to the patient, while gathering an assessment of current symptoms, an attempt to relay a sense of warmth, security, and trust which will serve as the foundation for ongoing treatment.

As previously discussed, the administration of psychotropic medications in the ED is sometimes necessary to stabilize an aggressive or violent patient. In these cases, the ED physician and mental health professional should maximize the patient’s sense of autonomy and self-determination; for example, the staff can allow the patient to choose the route of administration. Most likely, the patient feels that they have been violated in some way—either due to intrusive voices, paranoia, somatic delusions, or some other terrifying symptom—so the ED clinician should attempt to avoid coercion to the greatest degree possible.

Lastly, in many cases of schizophrenia, psychotic symptoms are ongoing, sometimes in spite of good pharmacological and psychotherapeutic management. The mere presence of psychotic symptoms in a patient who experiences such symptoms at baseline does not warrant 

, and it is unlikely that any such admission would do anything to improve the patient’s chronic illness.

Schizophrenia is a complex, disabling condition that presents a challenge to psychiatric and emergency medicine providers alike. Due in part to the lack of a comprehensive mental health system in the United States, patients with schizophrenia frequently present to the ED for diagnosis, treatment, and acute stabilization. Knowledge of diagnostic, pharmacological, and psychosocial elements of schizophrenia is essential for competent ED care. Of chief importance is the recognition that the patient with psychosis is in a psychologically vulnerable state, worsened by anxiety, and improved with understanding, empathy, and evidence-based symptom management.

 is the program director of the emergency medicine residency at Brandon Regional Hospital and an assistant professor of emergency medicine at the University of South Florida Morsani College of Medicine in Tampa, Florida. He currently practices emergency medicine and specializes in substance use disorder care in the emergency department setting in Brandon, Florida.

is an instructor of psychiatry at the University of Central Florida College of Medicine in Orlando, and an adjunct instructor of psychiatry at Tufts University School of Medicine in Boston, Masschusetts. He is a psychoanalytic psychotherapist in private practice in Tampa.

1. Soares-Weiser K, Maayan N, Bergman H, et al. 

2. Coentre R, Silva-Dos-Santos A, Talina MC. 

Retrospective study on structural neuroimaging in first-episode psychosis. 

Rosen’s Emergency Medicine: Concepts and Clinical Practice.

4. Griffin CE III, Kaye AM, Rivera Bueno F, Kaye AD. 

Benzodiazepine pharmacology and central nervous system-mediated effects.

5. Abou-Setta AM, Mousavi SS, Spooner C, et al. First-generation versus second-generation antipsychotics in adults: comparative effectiveness. In: 

Comparative Effectiveness Reviews, No. 63. 

Agency for Healthcare Research and Quality (US); 2012. Accessed August 11, 2021. 

https://www.ncbi.nlm.nih.gov/books/NBK107237/

6. Campillo A, MacDonald KS, Vilke GM, Wilson MP. The B52 combination is not frequently used in emergency departments and causes a high proportion of patients to fall asleep. 

7. Lebin JA, Akhavan AR, Hippe DS, et al. 

Psychiatric outcomes of patients with severe agitation following administration of prehospital ketamine.

9. Arieti S. Individual psychotherapy of schizophrenia. In: Arieti S, ed. 

Schizophrenia in the Emergency Department: Psychologically and Psychodynamically Informed Practices

It was my first overnight call shift, and I had just gotten a page for my third Emergency Department (ED) consult. I was the on-call psychiatry resident at the hospital, meaning I saw anyone coming into the ED due to a mental-health-related crisis. Many things can be categorized as mental health crises, but they are often cases dealing with suicidal thinking or action, psychosis, mania, and drug or alcohol use.

About 10 minutes after I got the page, I was sitting in the patient’s room listening to them describe the events of this past year between fits of tears. My heart pinched when I heard the inevitable: “I have been trying so hard to find anyone that can help, but the wait lists are so long…” In an ideal world I would have treatment options at my fingertips and distribute them with lightning speed to everyone coming to the hospital in a severe crisis. But, for many reasons, this is far from reality.

From the start of the COVID-19 pandemic, experts have 

 of an inevitable mental health crisis that would follow the devastation of such a massive unprecedented event. Now, almost a year and a half since the virus was 

 a global pandemic, this crisis has arrived. Despite this well-predicted and publicized outcome, not much was done to prepare systems. Importantly, few actually realize what a mental health crisis looks like at the frontlines—and just how many individuals and systems it affects.

This July, I started my first year as a psychiatry resident. On our first day, the program director sat me and my fellow interns down to have a frank discussion about what we were walking into. With our brand-new ID badges, we listened as she described mental health care as a stream that ebbs and flows. And right now, she emphasized, it was a tsunami. The ED at our hospital was filled with what are called 

. Boarders are patients that are in the ED exclusively for a psychiatric reason, but because the system is so backed up, there is nowhere else for them to go. So, what happens to them? They wait, and wait, and wait in a place never meant for more than an extremely short length of stay.

It is easy enough to read about the overflowing EDs, but something entirely different to witness it firsthand. Here is what it looks like: obtaining a patient’s history about a depressive episode resulting in a suicide attempt behind thin curtains, because there are no physical rooms available; telling a patient who is grieving for their spouse that we cannot immediately get them connected to a therapist because there is a shortage; telling a patient who has been waiting for a week already that they will need to wait over the weekend before they can get a bed somewhere else; limiting time for conducting therapy with any particular patient because other patients in acute crisis keep rolling in; and having a patient, who desperately needed a higher level of care, leave because the wait was too long.

An ED is not a long-term mental health facility, so when a length of stay in the ED approaches that of an inpatient psychiatry admission, there is a problem. The ED is an incredibly poor place for patients who are in a psychiatric crisis. The overall 

 of most EDs is not designed to be therapeutic for someone experiencing an exacerbation of a mental illness. In fact, many aspects exacerbate mental health struggles, including interrupted sleep, loud noises, frequent unknown visitors, and lack of windows or activity.

There are incredibly important downstream effects, as well. With half or more than half of the ED’s beds filled by those awaiting a higher level of psychiatric care, there is less room and bandwidth for those seeking the ED for other reasons. EDs are often partially staffed with mental health and psychiatric services, but the demand for their services frequently surpasses these clinicians’ capabilities. Additionally, EDs filled with boarding patients are a substantial cost to the health care system, estimated to be $

. And this cost was based on a boarding time of only about a day. With our ED patient list well over double its typical amount, it is safe to say that my colleagues and I were entering training during one of the most severe crises in recent history.

Looking for Solutions (In and Outside of the ED)

Solutions to psychiatric ED boarding were 

 even prior to the COVID-19 pandemic. Among them are: standardization of ED protocols for mental health and substance use issues; building partnership with community services; incorporating family and loved ones into care plans; and educating ED staff about trauma-informed care.

However, these ED-focused solutions do not address one of the major underlying problems: There is an ongoing inpatient bed shortage for both 

. Since deinstitutionalization, creating more inpatient psychiatry beds has not been a public priority—though in 

 this is beginning to shift. It is important to note that there is extreme variability between inpatient hospitals, and the inpatient setting is by no means the only solution to someone in a psychiatric crisis. However, there is still a clear need for more long-term mental health care facilities.

Aside from insufficient infrastructure, there is a shortage of psychiatrists and other mental health professionals. With the scale of the current crisis, patients are hard pressed to find any therapist or psychiatrist without a waitlist or who is even taking new patients. There was already a 

 of mental health practitioners, and the mental health crisis sparked by the pandemic has only exacerbated this shortage.

The phrase “just take care of the patient in front of you” rang in my head for my entire first call shift. These were the words of one of my attendings during our emergency psychiatry orientation. It is not new to physicians to feel as if they operate in a broken system. However, this feeling has been especially strong while training amidst such a severe crisis.

Despite the systemic issues I saw that day, those words rung true: our job is to focus on the one patient in front of us and do the best we can with them. In some ways, it is hard to hold that idea alongside the equally important one of needing to advocate for our patients when the system is failing them. But while I will be trained on how to take care of the patient in front of me, figuring out solutions for system failures will be left to my precious amount of free time. For now, despite the continued unanswered calls to action, I remain optimistic and tuned in, ready to use my voice and experience to advocate for real change for my patients.

is a first-year resident at the University of Vermont Medical Center

During the first day on the job, a psychiatry resident sees patients who need help, but there are problems with the system designed to help them. 

What the Mental Health Crisis Looks Like on the Ground Level

Schizophrenia affects roughly 1% of the global population and is a leading cause of suffering and disability worldwide. Despite advances in the pharmacological management of the disease, some patients with 

 remain consistently symptomatic, and others experience periodic exacerbations. Sadly, community services for those with chronic schizophrenic illness are lacking in many areas, rendering the emergency department (ED) a primary location for care of this severe mental disorder.

We wish to provide a psychologically- (and psychodynamically-) informed guide to the management of schizophrenia in the ED, incorporating relevant research in the areas of pharmacotherapy, psychology, and 

. One of us (Furiato) is an emergency medicine physician with interest in the management of acute psychiatric presentations. The other (Ruffalo) is a psychotherapist with interest in the psychotherapy of schizophrenia.

Attempts to distinguish schizophrenia from the psychotic symptoms that occur in other mental and medical disorders date at least to Kraepelin’s pioneering work in the late 1800s. Another German psychiatrist, Kurt Schneider proposed the “first-rank symptoms” of schizophrenia in 1939, and his theory held widespread popularity throughout the 20th century. A recent 

of Schneider’s first-rank symptoms (FRS) concluded that FRS correctly identifies individuals with schizophrenia 75% to 95% of the time.

Schneider’s FRS include: auditory hallucinations; thought withdrawal, insertion, or interruption; thought broadcasting; somatic hallucinations; delusional perception; and feelings or actions as made or influenced by external agents. While reliance on FRS alone may not be sufficient to diagnose schizophrenia,

Since the course of schizophrenia is generally chronic, and because comprehensive mental health systems are sorely lacking in many geographic regions of the United States, patients with schizophrenia presenting to EDs may be well-known to hospital staff. In cases wherein the patient is a poor historian, or past records are otherwise unable to be obtained, reliance on clinical skill, such as knowledge of FRS, is necessary to ascertain the diagnosis of 

In certain instances, such as a clinical suspicion of new onset schizophrenia or abnormal neurologic exam findings, use of brain imaging in the ED may be necessary to rule out organic disease of the nervous system. While a comprehensive review of brain imaging in psychosis is outside of the scope of this paper, 

 note that neuroimaging is particularly useful in first-episode psychosis when patients are of old age, have neurological symptoms, or have an atypical clinical picture.

In the ED setting, the first and most important consideration upon presentation of the acutely agitated patient with psychosis or schizophrenia is the level of risk of harm they have on themselves and on staff.

 Depending on the answer to this question, the route and type of medication can be tailored based on the specific patient. Speed of onset can dictate which route of administration is chosen, as those who are violent will need more rapid calming. These therapies should be used with combined or directly after failed verbal de-escalation techniques.

 (BZD), which are pharmacologically active on the gamma-aminobutyric acid (GABA) receptors, act on the central nervous system and are one of the most common medications used for calming and sedation in the ED.

 The largest concentrations exist in the thalamus, cortex, and cerebellum. There are many different subclasses of GABA receptors including the main α- and β- sub-units. The biochemical neurotransmitter effects include reversable binding of the excitatory neuroreceptors and neuronal firing. The primary clinical effects are anxiolysis, sedation, and amnesia.

This group of medications is also commonly used as the first-line agent of emergency treatment of seizure-disorders and epilepsy.

 Adverse events of BZDs can result in respiratory depression, hypoxia, hypotension, and paradoxical excitation reaction in those with organic brain disease. Depending on the lipid solubility of the agent and route of metabolism with patient comorbidities, half-lives vary widely as seen in the 

Patients who can be successfully verbally calmed and deescalated can be considered for therapy with oral management with BZDs alone or in combination with antipsychotics. For those who cannot be deescalated and pose a risk of injury to themselves and staff, these medications are commonly given intramuscularly in the ED, commonly with the help of physical restraints, and in combination with antipsychotics.

Antipsychotics can be broken down into 2 main categories in the emergency setting: first-generation (typical antipsychotics) and second-generation agents (atypical antipsychotics). The importance of the class distinction are the adverse side effects seen.

 Historically, the first-generation antipsychotics were developed for the treatment of schizophrenia. They act on the multiple dopaminergic receptor (D), anticholinergic, and histamine pathways. Each drug has its own mechanism of action and level of antagonism of those pathways. The hallmark drug of the first generation and one commonly used in the ED is haloperidol.

Haloperidol has been used to great success in treating the positive symptoms of schizophrenia. One of the main limitations, and ultimately a reason which prompted and led to the development of the second-generation drug class, was extrapyramidal symptoms such as tremor, slurred speech, akathisia, dystonia, and tardive dyskinesia. The 

further treats the negative symptoms of schizophrenia and improves upon the side effect profile of the first-generation group.

 Olanzapine and ziprasidone are commonly used in the ED from the second-generation class. Significant side effects of the second-generation drugs are sedation, hypotension, weight gain, and sexual dysfunction.

Many of the antipsychotics can be administered by mouth to those who are receptive to that method and calm enough for safety. They can also be administered by intramuscular and intravenous injection for those severely agitated.

 Careful monitoring of the patient’s respiratory status by cardiac monitoring and continuous pulse oximetry must be done after administration as side effects can also include respiratory depression and hypoxia. The regular combination of BZDs and antipsychotics can compound this risk. In addition, many of the antipsychotics can have cardiac electrophysiologic effects including prolonged QT intervals and the development of ventricular tachycardic arrythmias, necessitating EKG screening once the patient is chemically calmed.

Common combinations of BZDs and antipsychotics used in the ED include: lorazepam plus haloperidol or ziprasidone, midazolam plus haloperidol or ziprasidone. The addition of the antihistamine diphenhydramine is also sometimes added to the 2-drug cocktail discussed above for patients that are extremely violent. This practice is falling out of favor as seen in a recent retrospective cohort study.

In the prehospital and ED literature, ketamine has also been examined for the 

acute management of the violently agitated patient

 Ketamine is a dissociative agent that works at the N-methyl-D-aspartic (NMDA) receptor which is thought to play a partial role in the development in schizophrenia. Ketamine, when given intramuscularly, can produce more rapid de-escalation and sedation versus the more traditional method of BZDs plus an antipsychotic.

 The drawback to the use of ketamine is the theoretical possibility of exaggerating schizophrenic episodes due to activity on the NMDA receptors. There does not appear to be an increased need to inpatient psychiatric admission or ED psychiatric evaluation versus the traditional therapy.

Schizophrenia is a complex, multidimensional problem that requires appreciation of both biomedical and psychosocial aspects of disease management. This is true not only in the psychiatric treatment setting but also in the ED, since patients with schizophrenia may exhibit the most severe symptoms in the acute care setting. What follows is a brief review of some techniques for interviewing and treating the patient with 

Of perhaps greatest importance is the recognition that the patient’s heightened state of anxiety has contributed to their current psychotic disintegration.

Any attempt to challenge or question the validity of delusional themes will result in utter failure, so the ED clinician must avoid these types of confrontations. At the same time, the clinician should not tacitly agree with the patient’s deluded ideas but instead explain empathically that there are reasons why they are experiencing things differently. Again, the clinician must do everything they can to foster an environment in which some semblance of trust can be established. For the patient who is mute or otherwise difficult to engage in an interview, speaking about neutral subjects, such as the weather or sports, may help alleviate anxiety and open the patient up to answering some basic questions.

While it is of course necessary to gather some information from the patient to establish a history and determine appropriate disposition, the patient with schizophrenia may experience too many questions as an imposition. As Arieti writes, “The request for information is often interpreted by the patient as ‘an attempt to take something from him.’”

 should be less the collection of detailed information and more of a 

 while gathering an assessment of current symptoms, an attempt to relay a sense of warmth, security, and trust which will serve as the foundation for ongoing treatment.

As noted above, the administration of psychotropic medications in the ED is sometimes necessary to stabilize an aggressive or violent patient. In these cases, the ED physician and mental health professional should maximize the patient’s sense of autonomy and self-determination, for instance, by allowing the patient to choose the route of administration. The patient likely already feels that he has been violated in some way—either due to intrusive voices, paranoia, somatic delusions, or some other terrifying symptom—so the ED clinician should attempt to avoid the use of coercion to the greatest degree possible.

Lastly, we must note that in many cases of schizophrenia, psychotic symptoms are ongoing, sometimes in spite of good pharmacological and psychotherapeutic management. The mere presence of psychotic symptoms in a patient who experiences such symptoms at baseline does not warrant inpatient psychiatric hospitalization, and it is unlikely that any such admission would do anything to improve the patient’s chronic illness.

is the Program Director of the Emergency Medicine Residency at Brandon Regional Hospital and Assistant Professor of Emergency Medicine at the University of South Florida Morsani College of Medicine in Tampa, FL. He currently practices emergency medicine and specializes in substance use disorder care in the emergency department setting in Brandon, FL.

is Instructor of Psychiatry at the University of Central Florida College of Medicine in Orlando, FL, and Adjunct Instructor of Psychiatry at Tufts University School of Medicine in Boston, MA. He is a psychoanalytic psychotherapist in private practice in Tampa, FL. Disclaimer: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any other affiliated entities.

Retrospective study on structural neuroimaging in first-episode psychosis.

4. Griffin CE, Kaye AM, Bueno FR, Kaye AD. 

5. Abou-Setta AM, Mousavi SS, Spooner C, et al. First-generation versus second-generation antipsychotics in adults: comparative effectiveness. 

Agency for Healthcare Research and Quality (US).

6. Campillo A, MacDonald KS, Vilke GM, Wilson MP. 416 The B52 combination is not frequently used in emergency departments and causes a high proportion of patients to fall asleep. 

Research Forum Abstract Poster Session: Psychiatry.

The emergency department is a primary care location for patients with schizophrenia. Here’s how to manage schizophrenia in this particular setting in an informed and caring manner. 

Psychologically-Informed Management of Schizophrenia in the Emergency Department

During the past year, the COVID-19 pandemic has exacerbated the already severe substance abuse and mental health crises in the United States. Isolation and economic hardship have triggered spikes in depression, posttraumatic stress disorder, anxiety, and abuse of substances.

This unprecedented confluence of events, along with a welcome decrease in mental health stigma, has fueled a surge in demand for behavioral health services. According to a survey by the National Council for Behavioral Health (NCBH), 

of community behavioral health organizations reported greater demand for services through August 2020, while half of organizations offering substance use disorder (SUD) services saw demand jump last summer.

Unfortunately, many of these organizations are poorly positioned to meet this increased need for treatment services due to financial struggles. Nearly 65% of them have had to cancel programs, reschedule services, or turn away patients due to lack of revenue or pandemic-related restrictions. For some, the situation is dire: Nearly 40% of these organizations reported they may not last 6 months, given their revenue shortfalls.

On top of patient demand and financial struggles, the disjointed and siloed crisis management infrastructure makes it difficult for individuals in crisis to receive the care and resources they need. Lacking access to appropriate behavioral health care, many in crisis turn to emergency departments (EDs). An analysis 

 in February 2021 of nearly 190 million ED visits revealed that “visit rates for mental health conditions, suicide attempts, all drug and opioid overdoses, intimate partner violence, and child abuse and neglect were higher in mid-March through October 2020, during the COVID-19 pandemic, compared with the same period in 2019.”

Even before the pandemic put an immense strain on the behavioral health care system, the 

Substance Abuse and Mental Health Services Administration

 (SAMHSA) was pushing for the standardization of crisis management across the US for any behavioral health condition.

Yes, we need better crisis management, but what we really need is better crisis prevention.

Psychiatric Emergencies

“I Want to Do This for My Baby”: The Woes of Pregnancy and Addiction

Schizophrenia in the Emergency Department: Psychologically and Psychodynamically Informed Practices

What the Mental Health Crisis Looks Like on the Ground Level

Psychologically-Informed Management of Schizophrenia in the Emergency Department

The Need for Better Crisis Prevention

Teamwork and Trauma: a Conversation With Kasey Grewe, MD, and Niesha Voigt, MD

How to Talk to Patients About Firearms

Agree to Disagree: Excited Delirium Syndrome as Volatile as the Term Itself

Fast-Acting Options for Mood Disorders and Psychiatric Emergencies

Serving the Needs of the Many: Identifying Strategies for Better Care