SPECIAL REPORT: PSYCHIATRIC EMERGENCIES
Happy 40th birthday to emergency psychiatry! Many in our field point to a seminal article by Samuel Gerson, PhD, and Ellen Bassuk, MD, in the American Journal of Psychiatry in 19801 as first truly defining the subspecialty of emergency psychiatry. Since those days, we have seen impressive growth, scholarship, diversification, and impact throughout our area of care, and we can confidently state that at 40 years young our subspecialty has never been stronger.
Emergency psychiatry was preceded by the rise of emergency medicine, which became a distinct specialty in the late 1960s, and although a few years behind, emergency psychiatry has paralleled emergency medicine’s long-term development in many ways. Indeed, with overlaps in our patient populations, the fields often intersect and can be complementary. Recognizing this, the practitioners of emergency medicine may be some of emergency psychiatry’s biggest advocates. An emergency medicine physician has even served as the president of the American Association for Emergency Psychiatry (AAEP).
IN THIS SPECIAL REPORT
The Promise and Potential of Emergency Psychiatry
Scott Zeller, MD, Special Report Chair
The Field as a Master Class in Interviewing
Tony Thrasher, DO, DFAPA
CAHOOTS: A Model for Prehospital Mental Health Crisis Intervention
Ben Adam Climer and Brenton Gicker
10 Most Common Presentations in Emergency Psychiatry
Scott Zeller, MD, Special Report Chair
Infographic: Never a Dull Moment in Emergency Psychiatry
Scott Zeller, MD
The Psychiatric Interview
Tony Thrasher, DO, DFAPA
Emergency Psychiatry: The Intertwining of Physical and Mental Health
Scott Zeller, MD
In addition to the AAEP, emergency psychiatry also boasts a major annual conference dedicated to the field, the National Update on Behavioral Emergencies (NUBE). There are emergency psychiatry fellowships offered at multiple medical teaching institutions. Research efforts around the facets of the subspecialty abound, including labs with professors focused solely on behavioral emergencies, and there are numerous textbooks available covering all aspects. And it is now quite common to see young psychiatrists pursuing a career in emergency psychiatry.
Meanwhile, emergency psychiatry programs in all sizes and shapes are now found across the nation and in many foreign countries. They help to improve the care, timeliness, and access to more therapeutic environments, along with trained personnel, for patients that traditionally were held in medical emergency departments (EDs) for long hours waiting for a psychiatric inpatient bed. With the number of behavioral emergency chief complaints now estimated to be 1 in every 7 patients presenting to US EDs, the demand for these programs cannot be understated. Although Emergency psychiatry facilities go by many names, including CPEP (Comprehensive Psychiatric Emergency Program), PES (Psychiatric Emergency Services), EmPATH (Emergency Psychiatry Assessment, Treatment and Healing unit), they have demonstrated the ability to safely stabilize and discharge in less than 24 hours 75% or more of patients previously thought to need inpatient admission.2 These sites can provide immediate, compassionate, and effective care for many individuals, while also preserving the limited psychiatric inpatient beds for those who truly have no alternative.
Over the last year, we have seen enormous behavioral health impacts not only from the pandemic itself, but also from the stress of lockdowns, isolation, job insecurity, family dynamics, and loss of support networks. Last summer, the Centers for Disease Control (CDC) reported substantial increases in suicidal thoughts and substance abuse throughout the country. Shockingly, 11% of the CDC survey respondents reported suicidal ideation in the previous month, and for young adults aged 18 to 24 years, the number considering suicide jumped to an alarming 25%.3 Meanwhile, 2020 also opened many eyes to law enforcement’s role with behavioral crisis intervention, suggesting mental health professionals might be better suited for these tasks. Clearly, emergency psychiatry as a discipline will need to climb to even higher levels to assist in these considerable and impactful issues.
However, the road to positive change is not without its obstacles. Despite constituting such a large percentage of their trainees’ future patients, only about 25% of emergency medicine residencies provide formal instruction in acute psychiatric management.4 Many psychiatry residencies provide only minimal emergency psychiatry experience and education. Still, in too many hospitals, the default treatment for acute patients with acute psychiatric disordes remains little more than heavy sedation and physical restraints.
Given these challenges, how do we leverage the 40 years of advancement in emergency psychiatry to meet the myriad and growing demands of today, and continue to rise to the next level? Here are a few suggestions:
1 Begin the process of making emergency psychiatry an accredited, boarded subspecialty under the Accreditation Council for Graduate Medical Education (ACGME). Emergency psychiatry now meets the same standards and requirements for a psychiatry subspecialty as did consultation-liaison psychiatry, when it was formally recognized in 2005. An accredited subspecialty will be much more formidable in promoting appropriate care, and its tenets more difficult to overlook, even in peripheral training programs and outmoded hospitals.
2 Emergency psychiatry must further deepen its integration with emergency medicine and other adjacent specialties.Behavioral emergencies are encountered in all types of clinical settings by many different types of practitioners, and we must raise awareness with all health care professionals about our capabilities and innovative solutions.
3 We must educate our acute care health systems about the financial benefits of our programs and interventions. For example, a recent study published in the journal Academic Emergency Medicine demonstrated that a psychiatric emergency unit dramatically increased revenue for the affiliated medical ED, while providing better and more prompt care for behavioral emergency patients.5
4 Recognize that according to federal law, psychiatric emergencies are legally equivalent to medical emergencies, with the requirement of hospitals providing the same level of assessments and stabilizing efforts for patients as they would for those with chest pain or having experienced a car accident. We must stop thinking of a false dichotomy between the brain and the rest of the body. Mental health and physical health are completely intertwined, and should not be divided up and treated separately.
5 We need to promote a culture that eliminates the stigma of serious mental illness, while understanding that the symptoms of acute psychiatric illness can be just as painful and debilitating as broken bones and bleeding cuts. Patients who experience auditory hallucinations commanding them to hurt themselves or others are in extreme distress, as are those who are despondent and suicidal. Thus, they should not be rated as a low priority in emergency settings. We must send the message that psychiatric emergencies are as random as any other emergency; people do not plan to become suicidal any more than they would schedule themselves to have a heart attack. Life events are almost always unpredictable, so suggestions that we should plan services to try to catch a psychiatric emergency days before it happens will be about as successful as guessing tomorrow’s lotto numbers. Instead, we should be better prepared for all emergencies, and realize they will not cease any time soon, despite any bureaucrats’ assertion to the contrary.
Emergency psychiatry as its own field holds incredible promise, on top of an already remarkable short history. In the special articles of this month’s Psychiatric TimesTM, I trust you will see some of that for yourself.
Dr Zeller is vice president for acute psychiatry with the physician partnership Vituity and assistant clinical professor of psychiatry, University of California, Riverside. He is an Editorial Board Member of Psychiatric TimesTM.
1. Gerson S, Bassuk E. Psychiatric emergencies: an overview. Am J Psychiatry. 1980;137(1):1-11.
2. Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med. 2014;15(1):1-6.
3. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1049-1057.
4. Pickett J, Haas MRC, Fix ML, Tabatabai RR, et al. Training in the management of psychobehavioral conditions: a needs assessment survey of emergency medicine residents. AEM Educ Train. 2019;3:365-374.
5. Stamy C, Shane DM, Kannedy L, Van Heukelom P, et al. Economic evaluation of the emergency department after implementation of an emergency psychiatric assessment, treatment, and healing unit. Acad Emerg Med. September 1, 2020. Epub ahead of print. ❒