GUEST EDITORS NOTE

Primary Psychiatry. 2009;16(9):35-36

Emergency Psychiatry in the Twenty-first Century

Andrew Edmond Slaby, MD, PhD, MPH, and Manuel Trujillo, MD

mergency psychiatry was once deemed a necessary component of psychiatric care but not a preferred specialty interest. The practice of psychotherapy with or without psychopharmacotherapy was the usual career choice. Today, with decreasing hospital stays, rising acu-

ity of patients presenting for crisis care and the increasing comorbidity occurring with a particular disorder demands that all primary care providers and mental health professionals have some emergency psychiatric skill. The contributors to this issue address some of the essential components of state of art emergency care delivery, be it in an emergency room, crisis center, private office, on site in the community, or on an inpatient unit in a hospital. Kimberly Nordstrom, MD, JD, and Michael H. Allen, MD, present some general principles of emergency care delivery regardless of site of delivery. They focus on the review of risk factors for outpatient violence (diagnosis, the presence of positive symptoms, substance abuse and dependence) as an essential component of maintaining risk-awareness. They also review management measures that can prevent or help manage unexpected violence situations in outpatient practice or clinic settings, such as the use of panic-buttons, a written emergency plan appropriately rehearsed, and other means. David Baron, MSEd, DO, and colleagues discuss the evaluation and management of substance abuse emergencies. This article focuses on the clinical evaluation and initial treatment of patients with substance abuse problems who present to an emergency department or to an outpatient program managing high risk and/or dual diagnoses patients. The importance of making an accurate differential diagnosis and giving careful consideration of all relevant biopsychosocial factors is highlighted. The authors offer a treatment algorithm for emergency department clinicians and psychiatrists working in an emergency department setting to consider when assessing patients with intoxication or withdrawal from drugs of abuse. As emergency departments serve an important triage function, level of care determinates are highlighted since they frequently determine the success of the whole episode of treatment. The careful evaluation of risk for harm to self and others (intentional or unintentional) is described. In this population, medical risks are common and a medical cause must be excluded for each psychiatric mood or somatic symptom presented by the patient. Mark A. Novitsky, Jr., MD, and colleagues address the nonpharmacologic management of aggressive behavior during psychiatric emergencies. In addition to the mainstay treatments of medication administration and physical restraint, there are alternative treatment strategies that should be employed in the management of agitated patients. An understanding of the dynamics of violence is essential to implementing successful intervention, as violence is often a reaction to painful feelings of passivity and helplessness. Intervention using talk-down strategies during this period of escalation will frequently avert violent behavior. In such an escalating situation, the clinician must be sure that the patient can hear and respond, since a patient who is under the influence of alcohol or drugs is not a good candidate for talk-down techniques. By using a soft assertive voice and short sentences the clinician can rapidly determine if the patient is paying attention. Volume, tone, and rate of speech should also be carefully calibrated to reduce the tension and avoid undesired confrontations. A key ingredient of all interventions relates to affect management, which involves acknowledging the patients affect, validating the affect when appropriate, and encouraging the patient to talk about his/her feelings. In a fascinating exploration of genetic and neuroimaging

Dr. Slaby is clinical professor of psychiatry at New York University (NYU) School of Medicine. Dr. Trujillo is professor of psychiatry at NYU School of Medicine and director of the Division of Public and Global Psychiatry in New York City. Disclosure: Dr. Slaby reports no affiliation with or financial interest in any organization that may pose a conflict of interest. All of Dr. Trujillos financial compensation derives from full time employment at New York University Medical Center as a Professor of Psychiatry and Director of the Program in Public and Global Psychiatry, and from the private practice of psychiatry. Please direct all correspondence to: Andrew Edmond Slaby, MD, PhD, MPH, Clinical Professor of Psychiatry, New York University School of Medicine, 129B E. 71st St, New York, NY 10021-4201; Tel: 212-861-7189; Fax: 212-861-3407; E-mail: aeslaby@aol.com.

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Guest Editors Note

contributions to a new psychiatric clinical science, neuroethicist Laurence R. Tancredi, MD, JD, advocates for a future sciencebased evaluation of violence, where relevant genetic findings, linked with functional assessments of hyper or hypo function of key brain areas, can increase the predictive accuracy of our current risk assessment and provide broader and more sensitive targets for therapeutic interventions. Finally, Zoya Simakhodskaya, PhD, and colleagues at Bellevues renown Psychiatric Emergency Services detail how the use of sophisticated elements of care (mobile crisis teams linked to crisis clinics and extended observation beds) used at Bellevue Hospital in New York City as well as at other institutions have provided many intervention options beyond the classical admit or release algorhythm. Armed with these therapeutic options, clinicians who function in todays complex psychiatric emergency settings can make contributions to their patients tenure in the community, contribute to the reduction of premature readmissions, and add therapeutic value to the chain of community treatment options available to our severe and persistently mentally ill patients. A component of care that is critical to all acute psychiatric interventions is the development of a differential diagnosis, a tentative diagnosis, and a treatment plan.1 Mental health clinicians frequently collude with or are intimidated by members of other medical or surgical subspecialties who perceive psychiatry as a disposition rather than a specialty in the differential diagnosis of disorders of mood, thought, and behavior. In patients presenting with acute agitation, paroxismal anxiety, or even assaultive behavior, cardiologists would do well to include medical conditions such as pulmonary embolis, subactute bacterial endocarditis, and alcoholic cardiomayopathy in the differential diagnosis prior to concurring with a purely psychiatric diagnosis. An infectious disease specialist may correctly identify a depression as due to HIV disease but fail to evaluate suicide risk, requiring suicide precautions subsequent to marital status of the patient or mode of contraction. Patients who present with delirium or dementia may have episodes of other medical comorbidities contributing to the change in cognitive status, demanding an integrated treatment plan.

Research2 indicates that ~50% of psychiatric patients suffer undiagnosed medical disorders that may be etiologic or contributing to exacerbation of psychiatric disorders. In addition, >50% of newly presenting patients in the geriatric range have medical conditions contributing to their behavioral problem. Understanding the psychiatric epidemiology of a psychiatric disorder helps to distinguish a patient with a primary psychiatric disorder from a medical one. If age of onset, family history, and disease course do not comport with state of art knowledge of a psychiatric disorders course, the clinician should be weary of a psychiatric disorder and demand medico-surgical evaluation. One coauthor of this guest editorial (AES) consulted on a 55year-old woman who had been cleared by both medicine and neurology after presenting acutely psychotic without a personal or family history of psychiatric illness. She had been working steadily at the same position for 30 years without any problems. A second request was made to neurology, who asserted that the patient was schizophrenic. The patient was retained by psychiatry without any medication and in 2 hours the symptoms completely remitted. The patient then revealed she had severe unilateral headaches accompanied by nausea and sensitivity to lights. The patient during the few psychotic hours did complain of nausea and was provided with an emesis basin. A diagnosis of migraine was made (which did run in her family) and she was discharged with no further psychiatric symptoms. Physicians often protest that they have never seen a particular presentation of a medical disorder such as epilepsy presenting as psychosis. They may have in fact seen it but failed to recognize it as such. We hope that the material presented here will heighten awareness to the complexities of diagnoses of mood, thought, and behavior so that treatment plans may be crafted consistent with the primary etiologies and comorbidites encountered in an emergency setting. PP

REFERENCES
1. Slaby AE, Dubin WR, Baron DA. Other psychiatric emergences. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadocks Comprehensive Textbook of Psychiatry. 8th ed. New York, NY: Lippincott Williams & Wilkins; 2005:2453-2471. 2. Deutsch SI, Rosse RB. Evidence-based practice for the medical evaluation of the psychiatric patient in the emergency room. Psychiatry Weekly. July 14, 2008;3(25).

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