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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,

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

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.

 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. 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.

 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 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.

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 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.

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, Kaye AM, Bueno FR, 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. 

Agency for Healthcare Research and Quality (US).

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

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.

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. 

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.

SAMHSA’s goal is to standardize care quality and care delivery processes based on the best evidence-based practices. In other words, we know what works and how to keep individuals out of the medical care and criminal justice systems. We now need to implement the right processes broadly. A key part of the infrastructure is a new number for the National Suicide Prevention Lifeline (NSPL), which is run by SAMHSA. A bill signed into law late last year designates the 

 as the new, easy-to-remember phone number for anyone in crisis trying to reach the NSPL.

The 911 line currently is used for all emergencies, including mental health and substance use emergencies. But behavioral health crisis calls that result in the involvement of law enforcement sometimes result in tragic and traumatizing outcomes. In contrast, calls to the 988 mental health crisis number will be handled by trained NSPL counselors, who can in turn dispatch trained clinicians to a caller’s location. This behavioral health hotline number is expected to go live in July 2022.

Providing a hard-to-forget number will not make much of a difference, however, if we are not able to standardize the quality of crisis care across the US. Currently, there are about 

 that a caller could be patched through to, depending on area code.

 Those crisis lines offer varying degrees of services. Some are staffed by volunteers and non-clinicians who may lack experience and training, while others are staffed by veteran clinicians. Some can quickly connect callers to definitive assessment, treatment, and mobile crisis services. Others do not have these capabilities. 

To address this challenge, in February 2020, SAMHSA released its 

National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit

 Aimed at behavioral health authorities, agency administrators, service providers, and state and local leaders, this document defines national guidelines for crisis care. It also offers tips for implementing care that are in alignment with national guidelines as well as tools to evaluate whether systems are aligned to those guidelines.

The guidelines published by SAMHSA lay out a vision for a 

 integrated crisis system in which, based on the caller’s needs, the appropriate type of care can be quickly identified and provided. Nobody is turned away. Elements of this system include a regional, clinically staffed crisis call center that provides multichannel intervention capabilities and quality coordination of crisis care in real time, a mobile crisis team that can reach any person in the service area, and short-term (23 hours) crisis facilities for receiving and stabilizing patients in a nonhospital environment.

SAMHSA is encouraging all states to set up this standard clinical infrastructure. The states will need the technology to coordinate clinical activity and provide situational awareness—this is where care behavioral-health-specific coordination tools come in. An example of such a tool includes a cloud-based software platform with real-time availability of inpatient and outpatient treatment services, connections to treatment and social support services, and evidence-based assessment tools. It is important to identify a solution that helps clinicians close the loop on their patients’ care.

These goals and guidelines for behavioral crisis management are welcome news. Yet some would argue that instead of spending time and money 

 is not synonymous with prevention, but the goal of an end-to-end crisis system is to divert individuals from the inpatient beds and prisons, where they rarely get definitive behavioral healthcare. In addition, crisis systems provide preventative care: some of the data regarding crisis center calls shows that only 10% end up with a mobile team being dispatched to someone’s home. Of those calls, 80% are stabilized and do not require transfer to an inpatient care setting. Finally, of those who are transferred to a 23-hour crisis stabilization center, I estimate 75% are discharged home.

A very high percentage of the calls are being deescalated right on the line. But what then? With the right clinical and technology infrastructures in place, behavioral health crisis centers can refer callers to appropriate definitive assessment and treatment. In doing so, they can play a role in preventing callers from suffering a worsening of their current clinical condition, recurrence of this, or involvement with the medical care system and law enforcement.

To act in a preventative capacity, behavioral health organizations need technology infrastructure capabilities (

). States have been awarded planning grants to set up the clinical and technology infrastructures for behavioral health management. But how do we ensure the states are effectively implementing their technologies and clinical workflows?

Creating a set of standard quality measures is a logical step. For example, the standard length of time it takes from call to mobile crisis team disposition could be set to a time interval, based on geography. If a team cannot meet that benchmark, there should be consequences. After all, taxpayers are giving states a lot of money to set up these systems. We need to know they are working. There is simply too much at stake.

is Chief Medical Officer for Appriss Health, co-founder of OpenBeds, and an emergency medicine and critical care physician.

1. The National Council for Behavioral Health. COVID-19 continuing to impact behavioral health organizations in need of relief. Accessed June 29, 2021. 

https://www.thenationalcouncil.org/wp-content/uploads/2020/09/200903_NCBH_SCR.png

2. Holland KM, Jones C, Vivolo-Kantor AM, et al. Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. 

3. Substance Abuse and Mental Health Services Administration. National Guidelines for Behavioral Health Crisis Care: Best Practice Toolkit. February 2020. Accessed June 29, 2021. 

https://www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-care-02242020.pdf

4. Everett A. Groundbreaking developments in suicide prevention and mental health crisis service provision. Substance Abuse and Mental Health Services Administration. May 14, 2021. Accessed June 29, 2021. 

https://blog.samhsa.gov/2021/05/14/groundbreaking-developments-suicide-prevention

5. National Suicide Prevention Lifeline. Our network. Accessed June 29, 2021. 

https://suicidepreventionlifeline.org/our-network/

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

The Need for Better Crisis Prevention

The initial wave of COVID-19 flooded New York City hospitals with patients who urgently needed medical attention. Despite the potential dangers, psychiatrists and other physicians rushed to their aid. There were examples of inspiring teamwork and mutual support everywhere. At the same time, many physicians found themselves in new and unfamiliar roles, sometimes without the necessary mental health resources to cope with what they were seeing and doing.

, hosts Angela Coombs, MD, and Jennifer Sotsky, MD, talk to 

, about their experiences in the early days of the pandemic.

Many physicians have undergone traumatic experiences during the COVID-19 pandemic. If you or anyone you know needs mental health resources, consider contacting the 

’s national hotline (800-662-HELP) or the 

is an anesthesiology Critical Care Medicine Fellow at University of California, Los Angeles Health

is a PGY 3 resident and co-chair of the Psychiatry Residents Diversity Alliance at Columbia University Medical Center.

is a board-certified psychiatrist and assistant professor in Clinical Psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute. She serves as the medical director and team psychiatrist at ONTrackNY Washington Heights Community Service clinic. She completed her public psychiatry fellowship and adult psychiatry residency at Columbia University where she was a chief resident and co-organized the curriculum on racial/ethnic mental health disparities. In addition to her clinical work in the public sector, she also works in Columbia's psychiatric emergency room and has a private practice in Upper Manhattan.

is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of

Conquering Lyme Disease: Science Bridges the Great Divide

and has interests in medical education, psychotherapy, and medical humanities.

Thanks to Columbia University Department of Psychiatry for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry

In the early days of the COVID-19 pandemic, physicians were thrust into unfamiliar roles, where they sometimes had to make life and death decisions. Here are a few of their stories. 

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

Tony Thrasher, DO, DFAPA, provides a set of questions to include in your discussion with patients:

1. Do you have access to firearms? Risk assessment 

 go beyond this question, as access can be a varied term.

2. Why do you own them? This must be asked without judgment.

3. How do you store them? This is a good time to discuss locks, separate storage, and other important safety options.

4. Lastly, do you understnad the suicide risk firearms pose? 

is the president of the American Association for Emergency Psychiatry (AAEP) and the medical director of crisis services in Milwaukee county, Wisconsin.

These 4 questions can help in your discussion about firearm risk mitigation...

How to Talk to Patients About Firearms 

There is universal confusion around excited delirium syndrome (ExDS): What is it and how should it be treated? The short answer is we do not know the answers, and there are no comprehensive treatment guidelines or formal criteria, according to a panel presenting at the 2021 

American Psychiatric Association (APA) Annual Meeting

Representing the fields ofemergency medicine, psychiatry, psychology, and emergency medical service (EMS), the expert panel consisted of Leslie Zun, MD, MBA; Thom Dunn, PhD; Julie Owen, MD, MBA; and Sarah E. Slocum, MD.

Events in the recent past bring to light the importance of clarifying the differential diagnosis, signs and symptoms, and universal treatment protocols of ExDS, which to date remain unclear.

 dying at the hands of a police officer. In 2019, Elijah McClain, a 23-year-old massage therapist, was placed in a chokehold by law enforcement and sedated by EMS with 500 mg of ketamine, a tactic that is legal in Colorado to control ExDS. By the time he arrived at the hospital, he was brain dead; he died 3 days later.

, but one thing is clear. These and countless other incidents in the public eye have brought to the forefront use of force by police and in emergency settings.

Dunn, a psychologist who is also experienced in EMS, shared a stark example of excited delirium in a hospital setting where an adult male Black patient demonstrated signs of the condition. The presence of police seemed to intensify the patient’s agitation: He sweat profusely, stripped naked, shouted incomprehensibly, and flailed his arms. After multiple attempts to restrain him; police tased him. Emergency staff then administered ketamine; he subsequently died.

 on the matter, stating: “DSM-5 recognizes Delirium, hyperactive type, but the symptoms of this condition differ in many ways from the symptoms typically attributed to excited delirium (eg, superhuman strength, impervious to pain, etc.).”

They further noted that ExDS itself “is too non-specific to meaningfully describe and convey information about a person.” They concluded that 

 should not be used until a clear set of diagnostic criteria are validated.”

The panel concurred: The American Medical Association, the APA, the National Association of Medical Examiners, and the 

s still diverge in their recognition of ExDS.

With all this confusion, the panelist concluded with Slocum’s call for action: “We really need to address this condition as a group and figure out what’s going to be best for that patient.”

1. Council on Psychiatry and the Law. Position Statement on Concerns About Use of the Term “Excited Delirium” and Appropriate Medical Management in Out-of-Hospital Contexts. American Psychiatric Association. December 2020. Accessed May 13, 2021. 

https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-Use-of-Term-Excited-Delirium.pdf

2. ACEP Excited Delirium Task Force: White Paper Report on Excited Delirium Syndrome. American College of Emergency Physicians. September 10, 2009. Accessed May 13, 2021. 

https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/ems-and-disaster-preparedness/ems-resources/acep-excited-delirium-white-paper-final-form.pdf

What is excited delirium syndrome and how should it be treated? The short answer is we do not know.

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

Psychiatry may be lagging behind other branches of medicine in an important way.

“In the rest of medicine, as you increase the acuity you increase the number of treatments,” Nolan Williams, MD, told the attendees of the 2021 American Psychiatric Association (APA) Annual Meeting, but in psychiatry, “as we increase acuity we actually lose treatment options.”

Williams and his fellow presenters at a panel on rapidly acting medications

 all had the same question: How can psychiatrists design treatments to respond to sudden-onset conditions?

Williams, assistant professor of psychiatry and behavioral sciences at Stanford University Medical Center, described the situation as “emergency room purgatory.” Because of slow-acting treatments and limited hospital capacity, “the whole process of going through the inpatient unit can take several months,” he said. “The only treatment that we have available for these folks is ECT [electroconvulsive therapy.” But ECT is available in only 10% of US hospitals.

However, psychiatrists might have other options for fast-acting treatments. He shared 

showing that accelerated theta burst repetitive transcranial magnetic stimulation (r-TMS) had positive results for mood disorders, including MDD.

 R-TMS treatment works by stimulating the left dorsolateral prefrontal cortex (DLPFC). In MDD, the DLPFC may be failing to inhibit the subgenual cingulate, and the result of this network failure is cognitive impairment and inwardly directed negative thoughts,” Nolan explained. “By stimulating DLPFC, r-TMS corrects the mood imbalance and restores mood regulation.”

In initial numbers from his study of patients with a treatment-resistant mood disorder (TRD), Nolan found that after 5 days of sessions (10 hourly sessions at 1800 theta-burst pulses per hour), participants improved. On the Montgomery Asberg Depression Rating Scale (MADRS), he found an 80% average reduction of participants MADRS scores.

Another options for fast-acting treatment is ketamine. Charles DeBattista, MD, professor of psychiatry and behavioral sciences at Stanford University, presented evidence for its efficacy for TRD. He noted that ketamine is an anesthetic agent, a μ-opioid agonist, and while its effects on TRD are rapid, making it potentially helpful in psychiatric emergencies. “Often within a couple of hours to a day, patients experience a significant improvement, and the effects were sustained for a week or so,” he said. These effects did decrease after a week, but there is also evidence that repeated injections may lead to 

DeBattista also presented the option of esketamine, which has been fast tracked by the US Food and Drug Administration for treating TRD and acute suicidality in MDD. Multiple studies have found that it rapidly 

New mothers represent another population that might benefit from fast-acting medications. “Maternal mental health is something that’s been an enormous problem forever,” said Samantha Meltzer-Brody, MD, MPH. “Those of us that have the privilege of working with perinatal women are always struck by how debilitating PPD [postpartum depression] can be.” Rapidly acting medications could reduce mortality and morbidity, she said, and allow for more positive interactions between mothers and their newborns.

Although many selective serotonin reuptake inhibitors are approved to treat PPD, she pointed out that their initial effects may not be felt for weeks or even months, and many women’s symptoms do not respond to them. Meltzer-Brody, the Assad Meymandi Distinguished Professor and Chair in the University of North Carolina Department of Psychiatry, also considers an alternative to these medications: neurosteroids like brexanolone.

In a 2018 paper, Meltzer-Brody and her coauthors found brexanolone to be effective for

 Using the HDRS for measurement, the researchers found an average 8- to 10-point reduction in 12 hours, and around an 18-point reduction at 60 hours, the study’s primary endpoint. At day 30, participants average reduction remained, on average, 16 points down from baseline. The paper hypothesized that brexanolone works by increasing γ-aminobutyric acid (GABA) function, which appears to be inhibited during PPD.

With these new options, it seems psychiatry may not lag behind other branches of medicine for long. 

1. Williams N. Developing rapidly acting antidepressants: neurosteroids, dissociative agents (Ketamine Analogues and Psilocybin), and Accelerated Theta Burst r-TMS. Paper presented at: American Psychiatric Association Annual Meeting; May 1-3, 2021; virtual.

2. Nettekoven C, Volz LJ, Kutscha M, et al. Dose-dependent effects of theta burst rTMS on cortical excitability and resting-state connectivity of the human motor system. 

3. Li CT, Chen MH, Juan CH, et al. Efficacy of prefrontal theta-burst stimulation in refractory depression: a randomized sham-controlled study. 

4. Yip AG, George MS, Tendler A, et al. 61% of unmedicated treatment resistant depression patients who did not respond to acute TMS treatment responded after four weeks of twice weekly deep TMS in the Brainsway pivotal trial. 

5. Murrough JW, Perez AM, Pillemer S, et al. Rapid and longer-term antidepressant effects of repeated ketamine infusions in treatment-resistant major depression. 

6. Canuso CM, Singh JB, Fedgchin M, et al. Efficacy and safety of intranasal esketamine for the rapid reduction of symptoms of depression and suicidality in patients at imminent risk for suicide: results of a double-blind, randomized, placebo-controlled study. 

7. Fu DJ, Ionescu DF, Li X, et al. Esketamine nasal spray for rapid reduction of major depressive disorder symptoms in patients who have active suicidal ideation with intent: double-blind, randomized study (ASPIRE I). 

8. Meltzer-Brody S, Colquhoun H, Riesenberg R, et al. Brexanolone injection in post-partum depression: two multicentre, double-blind, randomised, placebo-controlled, phase 3 trials. 

What treatments could handle both psychiatric emergencies and long-standings mental health conditions—in a hurry?  

Fast-Acting Options for Mood Disorders and Psychiatric Emergencies

“There simply aren’t enough of us,” said Lori Raney, MD, in a scientific session, titled “

Unprecedented Access to Psychiatry: Expand Your Impact to Infinity and Beyond! Collaborative Care, eConsults, and ECHO Models

. The session addressed the vast shortage of psychiatrists and proposed alternative models of care to improve outcomes for more patients.

Speakers discussed the ever-widening gap between the shortage of psychiatrists and the overflowing flood of patients needing care. Shannon Kinnan, MD, a member of the APA Integrated Care Committee, spoke about the gravity of the problem of access to psychiatry. “The severity and the incidence of psychiatric illness continues to climb, which has only been magnified by the pandemic,” said Kinnan, assistant professor at Creighton University School of Medicine, Omaha, Nebraska. She worked in psychiatric services that had a wait list of 350 patients.

Collaborative care guides care across disciplines, including psychology, psychiatry, and primary care. The goal is to change practice, build community, and identify health professionals needing the most assistance.

Psychiatric Emergencies